Provider Demographics
NPI:1730136177
Name:ROSEN, AMY (PSYD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:ROSEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 NW LANDING RD
Mailing Address - Street 2:
Mailing Address - City:EAST HAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11937-5122
Mailing Address - Country:US
Mailing Address - Phone:631-708-6040
Mailing Address - Fax:
Practice Address - Street 1:64 COUNTY ROAD 39
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-5215
Practice Address - Country:US
Practice Address - Phone:631-702-1000
Practice Address - Fax:631-702-1010
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013842-1103TC0700X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02694728Medicaid