Provider Demographics
NPI:1871725937
Name:SKOGSTAD-DITSCH, ROXANNE TILLIE (MED, NAD-III, L)
Entity type:Individual
Prefix:MS
First Name:ROXANNE
Middle Name:TILLIE
Last Name:SKOGSTAD-DITSCH
Suffix:
Gender:F
Credentials:MED, NAD-III, L
Other - Prefix:MS
Other - First Name:ROXANNE
Other - Middle Name:TILLIE
Other - Last Name:SKOGSTAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED, NAD-III, L
Mailing Address - Street 1:1929 8TH AVE E.
Mailing Address - Street 2:
Mailing Address - City:INTERNATIONAL FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56649-3017
Mailing Address - Country:US
Mailing Address - Phone:218-283-9773
Mailing Address - Fax:218-283-2092
Practice Address - Street 1:1929 8TH AVE. E.
Practice Address - Street 2:
Practice Address - City:INTERNATIONAL FALLS
Practice Address - State:MN
Practice Address - Zip Code:56649-3017
Practice Address - Country:US
Practice Address - Phone:218-283-9773
Practice Address - Fax:218-283-2092
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-21
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261141103K00000X
ND261141103K00000X
MNL25101-1164W00000X
MN171R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No171R00000XOther Service ProvidersInterpreter