Provider Demographics
NPI:1740442177
Name:LANDRY, ROSHA L (RN, MSSW)
Entity type:Individual
Prefix:
First Name:ROSHA
Middle Name:L
Last Name:LANDRY
Suffix:
Gender:F
Credentials:RN, MSSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2266 N PROSPECT AVE
Mailing Address - Street 2:STE 616
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-6319
Mailing Address - Country:US
Mailing Address - Phone:414-289-0987
Mailing Address - Fax:
Practice Address - Street 1:2266 N PROSPECT AVE
Practice Address - Street 2:STE 616
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-6319
Practice Address - Country:US
Practice Address - Phone:414-289-0987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI126508-121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41002600Medicaid