Provider Demographics
NPI:1497780399
Name:ROSENBERG, SPENCER DANIEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:DANIEL
Last Name:ROSENBERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 RUSSI CT
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-7721
Mailing Address - Country:US
Mailing Address - Phone:916-984-5186
Mailing Address - Fax:916-984-5186
Practice Address - Street 1:2130 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3738
Practice Address - Country:US
Practice Address - Phone:916-879-2641
Practice Address - Fax:916-984-5186
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY7807103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PL78070Medicare ID - Type UnspecifiedPROVIDER NUMBER