Healthcare Provider Details

I. General information

NPI: 1487179941
Provider Name (Legal Business Name): KELVIN JAVIER ROSA MCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

URB. BRISAS DEL MAR
ISABELA PR
00662
US

IV. Provider business mailing address

PO BOX 1781
AGUADILLA PR
00605-1781
US

V. Phone/Fax

Practice location:
  • Phone: 787-462-1197
  • Fax:
Mailing address:
  • Phone: 787-462-1197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number20454
License Number StatePR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1197
Identifier TypeMEDICAID
Identifier StatePR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: