Provider Demographics
NPI:1154477347
Name:ROSENSTOCK, JUDITH MARA (PHD)
Entity Type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:MARA
Last Name:ROSENSTOCK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:566 S SAN VICENTE BLVD
Mailing Address - Street 2:#101
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-4650
Mailing Address - Country:US
Mailing Address - Phone:323-653-5279
Mailing Address - Fax:
Practice Address - Street 1:566 S SAN VICENTE BLVD
Practice Address - Street 2:#101
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-4650
Practice Address - Country:US
Practice Address - Phone:323-653-5279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5990103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY5990OtherPSYCHOLOGIST
CACP5990Medicare ID - Type UnspecifiedPSYCHOLOGIST