Provider Demographics
NPI:1336387166
Name:ROSENBAUM, ELLIOTT B (PSYD PA)
Entity Type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:B
Last Name:ROSENBAUM
Suffix:
Gender:M
Credentials:PSYD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3113 CORNELIA DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-5817
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4465 BAYMEADOWS RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-4732
Practice Address - Country:US
Practice Address - Phone:904-252-7979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-02
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist