Provider Demographics
NPI:1750728879
Name:ROSA, KEREN M
Entity type:Individual
Prefix:
First Name:KEREN
Middle Name:M
Last Name:ROSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 864
Mailing Address - Street 2:
Mailing Address - City:GUAYAMA
Mailing Address - State:PR
Mailing Address - Zip Code:00785-0864
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:BO. GUAMANI CARR 179
Practice Address - Street 2:KM 2.9 INTERIOR
Practice Address - City:GUAYAMA
Practice Address - State:PR
Practice Address - Zip Code:00785-0864
Practice Address - Country:US
Practice Address - Phone:787-678-0721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3301103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0323Medicaid