Provider Demographics
NPI:1750641189
Name:PUERTO, ROSEMARY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ROSEMARY
Middle Name:
Last Name:PUERTO
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:PO BOX 2802
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-7802
Mailing Address - Country:US
Mailing Address - Phone:510-914-7562
Mailing Address - Fax:
Practice Address - Street 1:160 CEDAR POINTE LOOP APT 311
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-4164
Practice Address - Country:US
Practice Address - Phone:510-914-7562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-18
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 390200000X
CAPSY34241103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1154933026OtherLA CONCORDIA PSYCHOTHERAPY AND WELLNESS CLINIC