=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629302518
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CANDACE MARIE ROSEN L.C.S.W.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2009
-----------------------------------------------------
Last Update Date | 09/24/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16822 S 2ND PL
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85048-2045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-460-7880
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16822 S 2ND PL
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85048-2045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-460-7880
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LCSW-2355
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------