Provider Demographics
NPI:1841766987
Name:ROSEN, DANA
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:ROSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 ELLENFILED STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4034
Mailing Address - Country:US
Mailing Address - Phone:401-444-6779
Mailing Address - Fax:
Practice Address - Street 1:167 POINT ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4771
Practice Address - Country:US
Practice Address - Phone:401-793-8808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-16
Last Update Date:2021-09-16
Deactivation Date:2021-04-06
Deactivation Code:
Reactivation Date:2021-07-22
Provider Licenses
StateLicense IDTaxonomies
390200000X
RIPS01982103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program