Healthcare Provider Details

I. General information

NPI: 1215584115
Provider Name (Legal Business Name): MATTHEW ROSENKILDE LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2019
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 S CENTER ST
MESA AZ
85210-1306
US

IV. Provider business mailing address

54 S CENTER ST
MESA AZ
85210-1306
US

V. Phone/Fax

Practice location:
  • Phone: 480-709-4635
  • Fax: 480-359-3270
Mailing address:
  • Phone: 480-709-4635
  • Fax: 480-359-3270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC-21819
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAC-17463
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-21819
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: