Basic Information
| Provider Information | |||||||||
| NPI: | 1700494002 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSADO | ||||||||
| FirstName: | ANGIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9114 37TH AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON HEIGHTS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113727920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187791831 | ||||||||
| FaxNumber: | 3476124126 | ||||||||
| Practice Location | |||||||||
| Address1: | 9114 37TH AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON HEIGHTS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113727920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187791831 | ||||||||
| FaxNumber: | 3476124126 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2020 | ||||||||
| LastUpdateDate: | 07/22/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 112047151 | 05 | NY | MEDICAID |