Healthcare Provider Details

I. General information

NPI: 1689760241
Provider Name (Legal Business Name): ELIOT JAY ROSEN MSW, DCSW, QCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13-3564 MOKU ST
PAHOA HI
96778
US

IV. Provider business mailing address

13-3564 MOKU ST
PAHOA HI
96778
US

V. Phone/Fax

Practice location:
  • Phone: 808-965-1279
  • Fax:
Mailing address:
  • Phone: 808-965-1279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3097
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: