Provider Demographics
NPI:1689760241
Name:ROSEN, ELIOT JAY (MSW, DCSW, QCSW)
Entity Type:Individual
Prefix:MR
First Name:ELIOT
Middle Name:JAY
Last Name:ROSEN
Suffix:
Gender:M
Credentials:MSW, DCSW, QCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13-3564 MOKU ST
Mailing Address - Street 2:
Mailing Address - City:PAHOA
Mailing Address - State:HI
Mailing Address - Zip Code:96778
Mailing Address - Country:US
Mailing Address - Phone:808-965-1279
Mailing Address - Fax:
Practice Address - Street 1:13-3564 MOKU ST
Practice Address - Street 2:
Practice Address - City:PAHOA
Practice Address - State:HI
Practice Address - Zip Code:96778
Practice Address - Country:US
Practice Address - Phone:808-965-1279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI30971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI52927401Medicaid
HI52927401Medicaid