Healthcare Provider Details

I. General information

NPI: 1043738206
Provider Name (Legal Business Name): FRANK ROSE PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2017
Last Update Date: 09/30/2022
Certification Date: 09/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7751 SQUIRREL LEVEL RD
NORTH DINWIDDIE VA
23803-7637
US

IV. Provider business mailing address

1050 TEMPLE AVE # 524
COLONIAL HEIGHTS VA
23834-2981
US

V. Phone/Fax

Practice location:
  • Phone: 804-695-6533
  • Fax: 855-978-2324
Mailing address:
  • Phone: 804-695-6633
  • Fax: 855-978-2324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810005750
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: