MEDICARE: MARIAH JOLLENE ROSAUER

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	1041C0700X	Clinical Social Worker	109892	CA
2	104100000X	Social Worker	109892	CA

General Provider Information

NPI Number	:	1215638143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIAH JOLLENE ROSAUER

Provider Business Mailing Address
First Line	:	1907 BOYS REPUBLIC DR
Second Line	:
City	:	CHINO HILLS
State	:	CA
Zip	:	91709-5447
Country	:	US
Telephone Number	:	909-628-1217
Fax Number	:	909-306-5427

Provider Business Practice Location Address
First Line	:	3624 MARGARET FOWLER CT
Second Line	:
City	:	CHINO HILLS
State	:	CA
Zip	:	91709-5456
Country	:	US
Telephone Number	:	909-740-3133
Fax Number	:	909-306-5427

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

Provider Enumeration Date	:	03/16/2023
Last Update Date	:	02/13/2024

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