Provider Demographics
NPI:1598857559
Name:DA ROSA, ANDREW B (MA)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:B
Last Name:DA ROSA
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5184 W LINDA LN
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-1979
Mailing Address - Country:US
Mailing Address - Phone:520-252-0049
Mailing Address - Fax:
Practice Address - Street 1:1819 S DOBSON RD
Practice Address - Street 2:SUITE 103
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-5664
Practice Address - Country:US
Practice Address - Phone:480-777-3707
Practice Address - Fax:480-368-0949
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-0050101YA0400X
AZLPC-12039101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ094684Medicaid