MEDICARE: MS. STEPHANIE DE LA ROSA

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	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1083816524
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. STEPHANIE DE LA ROSA

Provider Business Mailing Address
First Line	:	1515 PALM AVE
Second Line	:	SUITE A
City	:	SAN DIEGO
State	:	CA
Zip	:	92154-1011
Country	:	US
Telephone Number	:	619-429-4117
Fax Number	:	619-429-4116

Provider Business Practice Location Address
First Line	:	1515 PALM AVE
Second Line	:	SUITE A
City	:	SAN DIEGO
State	:	CA
Zip	:	92154-1011
Country	:	US
Telephone Number	:	619-429-4117
Fax Number	:	619-429-4116

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

Provider Enumeration Date	:	06/05/2007
Last Update Date	:	07/08/2007

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