Provider Demographics
NPI:1932731767
Name:BUTAC-ROESKE, MADELYN B (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MADELYN
Middle Name:B
Last Name:BUTAC-ROESKE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95-584 LELEIONA ST
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-2916
Mailing Address - Country:US
Mailing Address - Phone:808-428-7705
Mailing Address - Fax:
Practice Address - Street 1:95-1249 MEHEULA PKWY STE 195
Practice Address - Street 2:
Practice Address - City:MILILANI
Practice Address - State:HI
Practice Address - Zip Code:96789-1791
Practice Address - Country:US
Practice Address - Phone:808-428-7705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-10
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1806103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty