Provider Demographics
NPI:1720408412
Name:ROSEN, FRED M (AB MFT)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:M
Last Name:ROSEN
Suffix:
Gender:M
Credentials:AB MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 ELECTRIC AVE APT A
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-3797
Mailing Address - Country:US
Mailing Address - Phone:310-502-5659
Mailing Address - Fax:
Practice Address - Street 1:1551 OCEAN AVE STE 230
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-2110
Practice Address - Country:US
Practice Address - Phone:310-502-5659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-21
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37186106H00000X
CA#37186106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist