Provider Demographics
NPI:1104160118
Name:ROSEN, ALEXIS
Entity type:Individual
Prefix:MS
First Name:ALEXIS
Middle Name:
Last Name:ROSEN
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 1:22661 GRAY FOX DR
Mailing Address - Street 2:
Mailing Address - City:CANYON LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92587-7584
Mailing Address - Country:US
Mailing Address - Phone:909-732-2575
Mailing Address - Fax:
Practice Address - Street 1:22661 GRAY FOX DR
Practice Address - Street 2:
Practice Address - City:CANYON LAKE
Practice Address - State:CA
Practice Address - Zip Code:92587-7584
Practice Address - Country:US
Practice Address - Phone:909-732-2575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA72406106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist