Provider Demographics
NPI:1396047270
Name:BELISLE, ROGER H (PHD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:H
Last Name:BELISLE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 DOOLITTLE DR
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH AFB
Mailing Address - State:SD
Mailing Address - Zip Code:57706-4821
Mailing Address - Country:US
Mailing Address - Phone:605-385-3656
Mailing Address - Fax:
Practice Address - Street 1:2900 DOOLITTLE DR
Practice Address - Street 2:
Practice Address - City:ELLSWORTH AFB
Practice Address - State:SD
Practice Address - Zip Code:57706-4821
Practice Address - Country:US
Practice Address - Phone:605-385-3656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-24
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD577103TC0700X, 103TF0200X
VA0810004580103TC0700X, 103TF0200X
TX36625103TC0700X, 103TF0200X
577103TF0200X
103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical