Healthcare Provider Details

I. General information

NPI: 1790545440
Provider Name (Legal Business Name): MARTA I ROSALES MHP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2024
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 NEW INDIAN TRAIL CT
AURORA IL
60506-2411
US

IV. Provider business mailing address

4 INGLESHIRE RD
MONTGOMERY IL
60538-2047
US

V. Phone/Fax

Practice location:
  • Phone: 630-966-4139
  • Fax:
Mailing address:
  • Phone: 346-402-9506
  • 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: