Provider Demographics
NPI:1457799769
Name:STATOM, ROSA M (LPC)
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:M
Last Name:STATOM
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35901-4006
Mailing Address - Country:US
Mailing Address - Phone:256-490-0073
Mailing Address - Fax:256-261-2440
Practice Address - Street 1:405 S 8TH ST
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35901-4006
Practice Address - Country:US
Practice Address - Phone:256-490-0073
Practice Address - Fax:256-261-2440
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-08
Last Update Date:2013-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2169101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional