Provider Demographics
NPI:1760856363
Name:ROMAN, ROSA EILEEN (MA)
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:EILEEN
Last Name:ROMAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 CARAWAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34759
Mailing Address - Country:US
Mailing Address - Phone:407-433-5021
Mailing Address - Fax:
Practice Address - Street 1:1028 E OSCEOLA PARKWAY
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744
Practice Address - Country:US
Practice Address - Phone:407-720-4651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-19
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR004569103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist