Provider Demographics
NPI:1992991798
Name:ROSALES, GRACE A (PHD)
Entity type:Individual
Prefix:DR
First Name:GRACE
Middle Name:A
Last Name:ROSALES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2308 SCHADER DR
Mailing Address - Street 2:107
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2946
Mailing Address - Country:US
Mailing Address - Phone:310-948-7599
Mailing Address - Fax:
Practice Address - Street 1:11301 WILSHIRE BLVD
Practice Address - Street 2:#116AR
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90073-1003
Practice Address - Country:US
Practice Address - Phone:310-261-3426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-14
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21490103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist