MEDICARE: MRS. STACEY JILL ROSEN

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	235Z00000X	Speech-Language Pathologist	005746-1	NY

General Provider Information

NPI Number	:	1609011709
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STACEY JILL ROSEN

Provider Business Mailing Address
First Line	:	1459 PARK ST
Second Line	:
City	:	ATLANTIC BEACH
State	:	NY
Zip	:	11509-1623
Country	:	US
Telephone Number	:	516-371-1445
Fax Number	:

Provider Business Practice Location Address
First Line	:	1459 PARK ST
Second Line	:
City	:	ATLANTIC BEACH
State	:	NY
Zip	:	11509-1623
Country	:	US
Telephone Number	:	516-371-1445
Fax Number	:

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

Provider Enumeration Date	:	12/04/2008
Last Update Date	:	12/04/2008

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