Provider Demographics
NPI:1407957640
Name:ROSEN, IRA J (PH D)
Entity Type:Individual
Prefix:MR
First Name:IRA
Middle Name:J
Last Name:ROSEN
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:443 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-6733
Mailing Address - Country:US
Mailing Address - Phone:207-786-0270
Mailing Address - Fax:207-783-0500
Practice Address - Street 1:443 MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-6733
Practice Address - Country:US
Practice Address - Phone:207-786-0270
Practice Address - Fax:207-783-0500
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS206103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME003382OtherANTHEM BCBS