Basic Information
| Provider Information | |||||||||
| NPI: | 1356559785 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSE | ||||||||
| FirstName: | CORNELIUS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 351 S ST ANDREWS PL | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900204370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2136072010 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1926 BEVERLY BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900572402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2136072010 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.