Provider Demographics
NPI:1114122009
Name:ROSHAL, MARA (LCSW)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:ROSHAL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5105 W GOLDLEAF CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90056-1269
Mailing Address - Country:US
Mailing Address - Phone:323-298-3190
Mailing Address - Fax:323-298-3119
Practice Address - Street 1:5105 W GOLDLEAF CIR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90056-1269
Practice Address - Country:US
Practice Address - Phone:323-298-3190
Practice Address - Fax:323-298-3119
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS144991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical