Provider Demographics
NPI:1750790366
Name:ROSE, ANGELA (LMFT 98940)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:LMFT 98940
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 576
Mailing Address - Street 2:
Mailing Address - City:FELTON
Mailing Address - State:CA
Mailing Address - Zip Code:95018-0576
Mailing Address - Country:US
Mailing Address - Phone:831-471-7165
Mailing Address - Fax:
Practice Address - Street 1:2901 PARK AVE STE B10
Practice Address - Street 2:
Practice Address - City:SOQUEL
Practice Address - State:CA
Practice Address - Zip Code:95073-2831
Practice Address - Country:US
Practice Address - Phone:831-471-7165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-07
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70937101YM0800X
CA98940106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health