Provider Demographics
NPI:1336383702
Name:BASURTO-VARELA, ROSE (LCSW)
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:BASURTO-VARELA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 SAN GABRIEL BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-4394
Mailing Address - Country:US
Mailing Address - Phone:323-724-0019
Mailing Address - Fax:323-248-7044
Practice Address - Street 1:4160 MAINE AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-3304
Practice Address - Country:US
Practice Address - Phone:323-724-0019
Practice Address - Fax:323-248-7044
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-28
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS26275101YM0800X
CALCSW262751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health