Provider Demographics
NPI:1841505294
Name:ROSEN, MIRIAM ANN (M SED)
Entity type:Individual
Prefix:MRS
First Name:MIRIAM
Middle Name:ANN
Last Name:ROSEN
Suffix:
Gender:F
Credentials:M SED
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 71
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:NY
Mailing Address - Zip Code:13464-0071
Mailing Address - Country:US
Mailing Address - Phone:607-627-6358
Mailing Address - Fax:
Practice Address - Street 1:137 DEER FIELD LN N
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:NY
Practice Address - Zip Code:13464
Practice Address - Country:US
Practice Address - Phone:607-627-6358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst