Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YP2500X | Professional Counselor | 510-126 | WI |
Y | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | 2969-57 | WI |
NPI | 1144246182 |
---|---|
Provider Name | Michelle L Rose-Barajas |
First Address | Janesville, WI 53548-2970 |
Second Address | Janesville, WI 53548-2970 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/07/2006 |
Last Update Date | 12/11/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
43590100 | (05) | WI |