MEDICARE: DR. AMBER ROSE PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	19471	CA

General Provider Information

NPI Number	:	1023255999
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMBER ROSE PSYD

Provider Business Mailing Address
First Line	:	668 N COAST HWY
Second Line	:	SUITE 286
City	:	LAGUNA BEACH
State	:	CA
Zip	:	92651-1513
Country	:	US
Telephone Number	:	949-514-5825
Fax Number	:

Provider Business Practice Location Address
First Line	:	609 DEEP VALLEY DR
Second Line	:	SUITE 200
City	:	ROLLING HILLS ESTATES
State	:	CA
Zip	:	90274-3629
Country	:	US
Telephone Number	:	949-514-5825
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/14/2009
Last Update Date	:	01/14/2009

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