Provider Demographics
NPI:1710320080
Name:ROSEN, MARNI B (PSYD ATR)
Entity Type:Individual
Prefix:DR
First Name:MARNI
Middle Name:B
Last Name:ROSEN
Suffix:
Gender:F
Credentials:PSYD ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4235 BIRCHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-3860
Mailing Address - Country:US
Mailing Address - Phone:646-831-9165
Mailing Address - Fax:
Practice Address - Street 1:2130 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3026
Practice Address - Country:US
Practice Address - Phone:847-425-9708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-16
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008588103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical