Provider Demographics
NPI:1750550687
Name:ROE, JOSEPH F (PSY D)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:F
Last Name:ROE
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 297
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54451-0297
Mailing Address - Country:US
Mailing Address - Phone:715-748-4535
Mailing Address - Fax:715-748-0627
Practice Address - Street 1:136 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:WI
Practice Address - Zip Code:54451-1757
Practice Address - Country:US
Practice Address - Phone:715-748-4535
Practice Address - Fax:715-748-0627
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1375-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39231800Medicaid
WI000088235Medicare PIN
WI39231800Medicaid