Provider Demographics
NPI:1326040031
Name:ROSE, ROSALIND (LCSW)
Entity Type:Individual
Prefix:
First Name:ROSALIND
Middle Name:
Last Name:ROSE
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 1:366 N BROADWAY
Mailing Address - Street 2:SUITE 404
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-2025
Mailing Address - Country:US
Mailing Address - Phone:516-935-0068
Mailing Address - Fax:
Practice Address - Street 1:366 N BROADWAY
Practice Address - Street 2:SUITE 404
Practice Address - City:JERICHO
Practice Address - State:NY
Practice Address - Zip Code:11753-2025
Practice Address - Country:US
Practice Address - Phone:516-935-0068
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR021593-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN32881Medicare ID - Type Unspecified