Provider Demographics
NPI:1508201914
Name:MICHAEL D. ROSBERG PHD A PSYCHOLOGICAL CORPORATION
Entity Type:Organization
Organization Name:MICHAEL D. ROSBERG PHD A PSYCHOLOGICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DONETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MFT
Authorized Official - Phone:323-318-2520
Mailing Address - Street 1:2457 ENDICOTT ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90032-3047
Mailing Address - Country:US
Mailing Address - Phone:323-227-5252
Mailing Address - Fax:
Practice Address - Street 1:23622 CALABASAS RD
Practice Address - Street 2:SUITE 151
Practice Address - City:CALABASAS
Practice Address - State:CA
Practice Address - Zip Code:91302-1549
Practice Address - Country:US
Practice Address - Phone:818-693-5830
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-30
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15355103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty