Provider Demographics
NPI:1689395279
Name:ROSEBOROUGH, TERRY D
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:D
Last Name:ROSEBOROUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3667 N PLUM TREE AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92377-2701
Mailing Address - Country:US
Mailing Address - Phone:909-543-9974
Mailing Address - Fax:909-316-8292
Practice Address - Street 1:3667 N PLUM TREE AVE
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92377-2701
Practice Address - Country:US
Practice Address - Phone:909-543-9974
Practice Address - Fax:909-316-8292
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103T00000X
CA210038824103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103T00000XBehavioral Health & Social Service ProvidersPsychologist