Provider Demographics
NPI:1073020731
Name:ROSE, SHARLETT BARNETT (BS, MS)
Entity Type:Individual
Prefix:MS
First Name:SHARLETT
Middle Name:BARNETT
Last Name:ROSE
Suffix:
Gender:F
Credentials:BS, MS
Other - Prefix:
Other - First Name:SHARLETT
Other - Middle Name:B
Other - Last Name:ROSE SPENCER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2420 MARTIN RD STE 200
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-8610
Mailing Address - Country:US
Mailing Address - Phone:707-724-4398
Mailing Address - Fax:707-399-4521
Practice Address - Street 1:2420 MARTIN RD STE 200
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-8610
Practice Address - Country:US
Practice Address - Phone:707-724-4398
Practice Address - Fax:707-399-4621
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-03
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6315101YP2500X
106H00000X, 101Y00000X, 101YM0800X
CA112904106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA112904OtherAMFT
CA6315OtherAPCC