MEDICARE: MS. MARILYN JANE ROSE M.F.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MFC33608	CA

General Provider Information

NPI Number	:	1215040076
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARILYN JANE ROSE M.F.T.

Provider Business Mailing Address
First Line	:	3951 PERFORMANCE DR
Second Line	:	SUITE G
City	:	SACRAMENTO
State	:	CA
Zip	:	95838-3264
Country	:	US
Telephone Number	:	916-921-0828
Fax Number	:	916-648-8008

Provider Business Practice Location Address
First Line	:	3951 PERFORMANCE DR
Second Line	:	SUITE G
City	:	SACRAMENTO
State	:	CA
Zip	:	95838-3264
Country	:	US
Telephone Number	:	916-921-0828
Fax Number	:	916-648-8008

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2006
Last Update Date	:	11/09/2011

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