Healthcare Provider Details

I. General information

NPI: 1013787621
Provider Name (Legal Business Name): MARILYN ROSA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2024
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 ELM ST
PEEKSKILL NY
10566-3401
US

IV. Provider business mailing address

2 PATAKI FARM RD
PEEKSKILL NY
10566-6102
US

V. Phone/Fax

Practice location:
  • Phone: 914-739-0093
  • Fax:
Mailing address:
  • Phone: 917-536-2704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number033296
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: