Provider Demographics
NPI:1710012109
Name:ROSENBAUM, ROBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:ROSENBAUM
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 1:1040 ELM AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-3264
Mailing Address - Country:US
Mailing Address - Phone:562-279-1476
Mailing Address - Fax:562-279-0211
Practice Address - Street 1:1040 ELM AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-3264
Practice Address - Country:US
Practice Address - Phone:562-279-1476
Practice Address - Fax:562-279-0211
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5771103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical