Provider Demographics
NPI:1790069193
Name:ROSE, MILLICENT SHUNGU (LMFT)
Entity Type:Individual
Prefix:
First Name:MILLICENT
Middle Name:SHUNGU
Last Name:ROSE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:MILLICENT
Other - Middle Name:SHUNGU
Other - Last Name:MAZAIWANA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3200 MOTOR AVENUE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3200 MOTOR AVENUE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034
Practice Address - Country:US
Practice Address - Phone:310-836-1223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-04
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist