Provider Demographics
NPI:1396000667
Name:ROSALES, CARMEN LETICIA
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:LETICIA
Last Name:ROSALES
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 1:3763 EVANS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9302
Mailing Address - Country:US
Mailing Address - Phone:239-333-1604
Mailing Address - Fax:
Practice Address - Street 1:10140 DEER RUN FARMS RD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-1045
Practice Address - Country:US
Practice Address - Phone:239-333-1604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical