Provider Demographics
NPI:1396101655
Name:ROSA, SAMUEL CHRISTOPHER (LPC)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:CHRISTOPHER
Last Name:ROSA
Suffix:
Gender:M
Credentials:LPC
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 18421
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39404-8400
Mailing Address - Country:US
Mailing Address - Phone:601-288-4915
Mailing Address - Fax:
Practice Address - Street 1:1505 SUNSET RD
Practice Address - Street 2:
Practice Address - City:COLLINS
Practice Address - State:MS
Practice Address - Zip Code:39428-6389
Practice Address - Country:US
Practice Address - Phone:601-288-4915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-01
Last Update Date:2016-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1666101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional