Provider Demographics
NPI:1356119549
Name:ROSE, ANGELYN NICOLE (LMFT)
Entity type:Individual
Prefix:
First Name:ANGELYN
Middle Name:NICOLE
Last Name:ROSE
Suffix:
Gender:
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3019 OCEAN PARK BLVD # 234
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-3004
Mailing Address - Country:US
Mailing Address - Phone:424-241-3896
Mailing Address - Fax:
Practice Address - Street 1:3019 OCEAN PARK BLVD # 234
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-3004
Practice Address - Country:US
Practice Address - Phone:424-241-3896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-18
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11161101YM0800X
CA154941106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health