Provider Demographics
NPI:1801988100
Name:ROSENBERRY, CAROLYN E (PHD)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:E
Last Name:ROSENBERRY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13809 FIDDLERS POINT DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-5427
Mailing Address - Country:US
Mailing Address - Phone:904-220-7572
Mailing Address - Fax:
Practice Address - Street 1:13809 FIDDLERS POINT DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-5427
Practice Address - Country:US
Practice Address - Phone:904-220-7572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0005522103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54134AMedicare ID - Type Unspecified