Basic Information
| Provider Information | |||||||||
| NPI: | 1154381127 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSENBAUM | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1441 N 12TH ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850062837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024954577 | ||||||||
| FaxNumber: | 6024173549 | ||||||||
| Practice Location | |||||||||
| Address1: | 1012 E WILLETTA ST | ||||||||
| Address2: | 3RD FLOOR AND 5TH FLOOR | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850062749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022392361 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 06/22/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 3323 | AZ | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 912221 | 05 | AZ | MEDICAID |