Provider Demographics
NPI:1972160018
Name:ELDRED, ROSSETTA DIVINA
Entity Type:Individual
Prefix:
First Name:ROSSETTA
Middle Name:DIVINA
Last Name:ELDRED
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 FREMONT ST
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49017-3764
Mailing Address - Country:US
Mailing Address - Phone:269-589-0127
Mailing Address - Fax:
Practice Address - Street 1:11 GREEN ST
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49014-4028
Practice Address - Country:US
Practice Address - Phone:269-965-1148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-23
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011041201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical