Provider Demographics
NPI:1366701591
Name:ROSE, SANDRA (MED)
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 S BARRINGTON AVE
Mailing Address - Street 2:SUITE 309
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025
Mailing Address - Country:US
Mailing Address - Phone:323-457-3370
Mailing Address - Fax:
Practice Address - Street 1:548 PARK AVE
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01603-2537
Practice Address - Country:US
Practice Address - Phone:774-823-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-08
Last Update Date:2025-09-05
Deactivation Date:2024-07-23
Deactivation Code:
Reactivation Date:2025-09-04
Provider Licenses
StateLicense IDTaxonomies
CAAMFT141488106H00000X
103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral