Provider Demographics
NPI:1972020980
Name:ROSE, DEENA MARIE (MFT INTERN)
Entity Type:Individual
Prefix:
First Name:DEENA
Middle Name:MARIE
Last Name:ROSE
Suffix:
Gender:F
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1528 EUREKA RD STE 101
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3047
Mailing Address - Country:US
Mailing Address - Phone:916-500-4535
Mailing Address - Fax:
Practice Address - Street 1:1528 EUREKA RD STE 101
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3047
Practice Address - Country:US
Practice Address - Phone:916-500-4535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF94864106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist