Provider Demographics
NPI:1619454014
Name:ROSA, MICHAEL LUIS
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:LUIS
Last Name:ROSA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 E 149TH ST APT 8
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-5347
Mailing Address - Country:US
Mailing Address - Phone:646-642-6797
Mailing Address - Fax:
Practice Address - Street 1:4277 65TH PL
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-5054
Practice Address - Country:US
Practice Address - Phone:718-429-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104098104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker