MEDICARE: ROSE HARTZELL-CUSHANICK PHD, EDS, LMFT

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	106H00000X	Marriage & Family Therapist	53079	CA

General Provider Information

NPI Number	:	1770952533
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROSE HARTZELL-CUSHANICK PHD, EDS, LMFT

Provider Business Mailing Address
First Line	:	5555 RESERVOIR DR STE 300
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-5194
Country	:	US
Telephone Number	:	619-265-8865
Fax Number	:	619-265-7696

Provider Business Practice Location Address
First Line	:	5555 RESERVOIR DR STE 300
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-5194
Country	:	US
Telephone Number	:	619-265-8865
Fax Number	:	619-265-7696

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

Provider Enumeration Date	:	09/22/2015
Last Update Date	:	09/22/2015

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