Healthcare Provider Details

I. General information

NPI: 1114511649
Provider Name (Legal Business Name): THEODORE ROSA LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2021
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24481 DETROIT RD STE 201
WESTLAKE OH
44145-1557
US

IV. Provider business mailing address

1276 COVE AVE APT 2
LAKEWOOD OH
44107-2147
US

V. Phone/Fax

Practice location:
  • Phone: 440-310-6361
  • Fax:
Mailing address:
  • Phone: 440-225-2371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE.2607681
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: