Provider Demographics
NPI:1053858084
Name:LA ROSA DE LA ROSA, CARMEN (BASIC SKILLS)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:LA ROSA DE LA ROSA
Suffix:
Gender:F
Credentials:BASIC SKILLS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 S EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-3916
Mailing Address - Country:US
Mailing Address - Phone:702-703-5537
Mailing Address - Fax:
Practice Address - Street 1:7301 SAYBROOK POINT DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-3206
Practice Address - Country:US
Practice Address - Phone:702-444-8644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-29
Last Update Date:2017-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician