Provider Demographics
NPI:1578629853
Name:ROSE, SONNY (RN, MFT INTERN)
Entity Type:Individual
Prefix:
First Name:SONNY
Middle Name:
Last Name:ROSE
Suffix:
Gender:M
Credentials:RN, MFT INTERN
Other - Prefix:
Other - First Name:MARCIA
Other - Middle Name:
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1001 SOUTH 57TH STREET
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94804
Mailing Address - Country:US
Mailing Address - Phone:925-895-5716
Mailing Address - Fax:510-374-7033
Practice Address - Street 1:1001 SOUTH 57TH STREET
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94804
Practice Address - Country:US
Practice Address - Phone:925-895-5716
Practice Address - Fax:510-374-7033
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFIL42275106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist