Healthcare Provider Details

I. General information

NPI: 1144889064
Provider Name (Legal Business Name): STEPHEN M ROOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2019
Last Update Date: 06/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 HOSPITAL RD
SONORA CA
95370-5227
US

IV. Provider business mailing address

2 S GREEN ST
SONORA CA
95370-4618
US

V. Phone/Fax

Practice location:
  • Phone: 209-533-6245
  • Fax:
Mailing address:
  • Phone: 209-533-6245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT112531
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: