Provider Demographics
NPI:1851805923
Name:ROSA, CATHERINE
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:
Last Name:ROSA
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 1:11711 LEISURE LN E
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33773-4752
Mailing Address - Country:US
Mailing Address - Phone:516-445-0407
Mailing Address - Fax:
Practice Address - Street 1:11711 LEISURE LN E
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33773-4752
Practice Address - Country:US
Practice Address - Phone:516-445-0403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-27
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY$$$$$$$$$Medicaid