Provider Demographics
NPI:1215040076
Name:ROSE, MARILYN JANE (MFT)
Entity Type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:JANE
Last Name:ROSE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3951 PERFORMANCE DR
Mailing Address - Street 2:SUITE G
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95838-3264
Mailing Address - Country:US
Mailing Address - Phone:916-921-0828
Mailing Address - Fax:916-648-8008
Practice Address - Street 1:3951 PERFORMANCE DR
Practice Address - Street 2:SUITE G
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95838-3264
Practice Address - Country:US
Practice Address - Phone:916-921-0828
Practice Address - Fax:916-648-8008
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC33608106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist