Provider Demographics
NPI:1649401175
Name:ROSA, MARIGLORY (PSYD)
Entity Type:Individual
Prefix:
First Name:MARIGLORY
Middle Name:
Last Name:ROSA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:COND. COLINA REAL, AVE. FELISA R. DE GAUTIER
Mailing Address - Street 2:APT 301
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926
Mailing Address - Country:US
Mailing Address - Phone:787-690-9040
Mailing Address - Fax:
Practice Address - Street 1:12 AVE ALEJANDRINO
Practice Address - Street 2:URB. VILLA CLEMENTINA
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00969-4712
Practice Address - Country:US
Practice Address - Phone:787-690-9040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-31
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2147103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical