Provider Demographics
NPI:1710044102
Name:ROSEN, LAURENCE ROY (MS)
Entity type:Individual
Prefix:MR
First Name:LAURENCE
Middle Name:ROY
Last Name:ROSEN
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 MOUNTAINSIDE PARK TER
Mailing Address - Street 2:
Mailing Address - City:UPPER MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07043-1209
Mailing Address - Country:US
Mailing Address - Phone:973-783-8673
Mailing Address - Fax:
Practice Address - Street 1:16 MOUNTAINSIDE PARK TER
Practice Address - Street 2:
Practice Address - City:UPPER MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07043-1209
Practice Address - Country:US
Practice Address - Phone:973-783-8673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC046093001041C0700X
NYR028928-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJR0007040Medicare UPIN
NYR0007040Medicare UPIN