Provider Demographics
NPI:1154868370
Name:ROSE, MARTA MARIA
Entity Type:Individual
Prefix:
First Name:MARTA
Middle Name:MARIA
Last Name:ROSE
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 1:2579 SAN PABLO AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-1159
Mailing Address - Country:US
Mailing Address - Phone:510-446-7161
Mailing Address - Fax:
Practice Address - Street 1:2579 SAN PABLO AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-1159
Practice Address - Country:US
Practice Address - Phone:510-446-7161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25072106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist