Provider Demographics
NPI:1780447243
Name:ROZELLE, MARYL
Entity type:Individual
Prefix:
First Name:MARYL
Middle Name:
Last Name:ROZELLE
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 1:406 LAKE VISTA DR
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-1906
Mailing Address - Country:US
Mailing Address - Phone:717-406-5067
Mailing Address - Fax:
Practice Address - Street 1:112 CANDLEWOOD CT
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-2653
Practice Address - Country:US
Practice Address - Phone:434-258-0591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-06
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701013557101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health