=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902141559
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RODOLFO JOSE ROSADO PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2012
-----------------------------------------------------
Last Update Date | 04/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1065 SOUTHERN BLVD
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10459-2417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-984-6768
-----------------------------------------------------
Fax | 203-846-4109
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1065 SOUTHERN BLVD
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10459-2417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-589-7440
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 001841
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 011837
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 011837
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------