Provider Demographics
NPI:1417603531
Name:LA ROSA, KAMILLE
Entity type:Individual
Prefix:
First Name:KAMILLE
Middle Name:
Last Name:LA ROSA
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 1:196 S INDUSTRIAL DR
Mailing Address - Street 2:
Mailing Address - City:SALINE
Mailing Address - State:MI
Mailing Address - Zip Code:48176-9175
Mailing Address - Country:US
Mailing Address - Phone:734-944-3446
Mailing Address - Fax:
Practice Address - Street 1:196 S INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:SALINE
Practice Address - State:MI
Practice Address - Zip Code:48176-9175
Practice Address - Country:US
Practice Address - Phone:734-944-3446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-28
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6352000653103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical