Healthcare Provider Details

I. General information

NPI: 1518255009
Provider Name (Legal Business Name): STEPHANIE ROSALES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2011
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7145 MAGNOLIA AVE
RIVERSIDE CA
92504-3805
US

IV. Provider business mailing address

325 N PALM AVE
RIALTO CA
92376-5827
US

V. Phone/Fax

Practice location:
  • Phone: 951-686-2020
  • Fax: 951-686-2121
Mailing address:
  • Phone: 909-961-4090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberLEP3111
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLEP3111
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License NumberLEP3111
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberLEP3111
License Number StateCA
# 6
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-12-1015
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: