Provider Demographics
NPI:1003153057
Name:DE LA ROSA, EDITA
Entity Type:Individual
Prefix:
First Name:EDITA
Middle Name:
Last Name:DE LA ROSA
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 1:535 8TH AVE
Mailing Address - Street 2:2ND FL
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10018-4305
Mailing Address - Country:US
Mailing Address - Phone:212-787-9700
Mailing Address - Fax:
Practice Address - Street 1:535 8TH AVE
Practice Address - Street 2:2ND FL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-4305
Practice Address - Country:US
Practice Address - Phone:212-787-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-10
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator