MEDICARE: DR. SUSAN CAROL ROSE PH.D.

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	103T00000X	Psychologist	PSY8073	CA

General Provider Information

NPI Number	:	1669461257
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN CAROL ROSE PH.D.

Provider Business Mailing Address
First Line	:	16055 VENTURA BLVD
Second Line	:	STE 605
City	:	ENCINO
State	:	CA
Zip	:	91436-2601
Country	:	US
Telephone Number	:	818-788-6653
Fax Number	:

Provider Business Practice Location Address
First Line	:	16055 VENTURA BLVD
Second Line	:	STE 605
City	:	ENCINO
State	:	CA
Zip	:	91436-2601
Country	:	US
Telephone Number	:	818-788-6653
Fax Number	:

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

Provider Enumeration Date	:	10/17/2005
Last Update Date	:	07/08/2007

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