Provider Demographics
NPI:1154609311
Name:ROSA, ELAINE (PSYD)
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:
Last Name:ROSA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11835 W OLYMPIC BLVD STE 1265E
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-5814
Mailing Address - Country:US
Mailing Address - Phone:310-994-6499
Mailing Address - Fax:310-273-5056
Practice Address - Street 1:11835 W OLYMPIC BLVD STE 1265E
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064
Practice Address - Country:US
Practice Address - Phone:310-994-6499
Practice Address - Fax:310-273-5056
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY25386103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical