Healthcare Provider Details

I. General information

NPI: 1962626648
Provider Name (Legal Business Name): THOMAS ALLEN ROSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1756 S LEWIS RD
CAMARILLO CA
93012-8520
US

IV. Provider business mailing address

3022 S E ST
OXNARD CA
93033-5247
US

V. Phone/Fax

Practice location:
  • Phone: 805-383-3669
  • Fax:
Mailing address:
  • Phone: 805-483-9071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: