1891990362 NPI number — DR. FRAYDA ILENE ROSEN PSYD

Table of content: DR. FRAYDA ILENE ROSEN PSYD (NPI 1891990362)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891990362 NPI number — DR. FRAYDA ILENE ROSEN PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSEN
Provider First Name:
FRAYDA
Provider Middle Name:
ILENE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891990362
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 WEST UNIVERSITY AVENUE
Provider Second Line Business Mailing Address:
STE 303
Provider Business Mailing Address City Name:
ST PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-644-1813
Provider Business Mailing Address Fax Number:
651-644-1870

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 WEST UNIVERSITY AVENUE
Provider Second Line Business Practice Location Address:
STE 303
Provider Business Practice Location Address City Name:
ST PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-644-1813
Provider Business Practice Location Address Fax Number:
651-644-1870
Provider Enumeration Date:
06/15/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)