Provider Demographics
NPI:1104301340
Name:ROSELLO, ROSA
Entity type:Individual
Prefix:
First Name:ROSA
Middle Name:
Last Name:ROSELLO
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 1:8791 NW 11TH CT
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-4708
Mailing Address - Country:US
Mailing Address - Phone:786-337-3281
Mailing Address - Fax:
Practice Address - Street 1:8791 NW 11TH CT
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-4708
Practice Address - Country:US
Practice Address - Phone:786-337-3281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-02
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018575400Medicaid