=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629138037
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA LYNN ROSE PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2829 WATT AVE SUITE 150
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95821-6237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-482-1132
-----------------------------------------------------
Fax | 916-979-3503
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2829 WATT AVE SUITE 150
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95821-6237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-482-1132
-----------------------------------------------------
Fax | 916-979-3503
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY16256
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------