Provider Demographics
NPI:1558460568
Name:ROSE, LORRAINE (PHD)
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9107 WILSHIRE BLVD.
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210
Mailing Address - Country:US
Mailing Address - Phone:310-274-7228
Mailing Address - Fax:
Practice Address - Street 1:9107 WILSHIRE BLVD.
Practice Address - Street 2:SUITE 200
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-5522
Practice Address - Country:US
Practice Address - Phone:310-274-7228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12803103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP12803Medicare ID - Type Unspecified