Healthcare Provider Details

I. General information

NPI: 1528517315
Provider Name (Legal Business Name): ANITA MASTMAN ROSEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2016
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8417 WASHINGTON PL NE
ALBUQUERQUE NM
87113-1720
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-263-4066
  • Fax:
Mailing address:
  • Phone: 505-923-4583
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberI-3599
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberC-3599
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-3599
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: