Healthcare Provider Details

I. General information

NPI: 1386305654
Provider Name (Legal Business Name): COURTNEY ROSA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2022
Last Update Date: 01/07/2022
Certification Date: 01/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 NEW YORK AVE
TRENTON NJ
08638-3913
US

IV. Provider business mailing address

2701 RENAISSANCE BLVD FL 4
KING OF PRUSSIA PA
19406-2781
US

V. Phone/Fax

Practice location:
  • Phone: 855-740-1921
  • Fax:
Mailing address:
  • Phone: 484-803-9663
  • Fax: 484-393-4096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: