Provider Demographics
NPI:1417475120
Name:ROSE, CONSTANCE (PHD)
Entity type:Individual
Prefix:DR
First Name:CONSTANCE
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 3RD AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-1919
Mailing Address - Country:US
Mailing Address - Phone:347-470-3146
Mailing Address - Fax:
Practice Address - Street 1:600 3RD AVE FL 2
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-1919
Practice Address - Country:US
Practice Address - Phone:347-470-3146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-01
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NY026647103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician