Provider Demographics
NPI:1861532152
Name:ROBIN ROSEN
Entity type:Organization
Organization Name:ROBIN ROSEN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:G
Authorized Official - Last Name:ROSEN
Authorized Official - Suffix:
Authorized Official - Credentials:LADC
Authorized Official - Phone:860-875-2578
Mailing Address - Street 1:384 MERROW RD STE D
Mailing Address - Street 2:
Mailing Address - City:TOLLAND
Mailing Address - State:CT
Mailing Address - Zip Code:06084-3957
Mailing Address - Country:US
Mailing Address - Phone:860-875-2578
Mailing Address - Fax:860-875-9963
Practice Address - Street 1:384 MERROW RD STE D
Practice Address - Street 2:
Practice Address - City:TOLLAND
Practice Address - State:CT
Practice Address - Zip Code:06084-3957
Practice Address - Country:US
Practice Address - Phone:860-875-2578
Practice Address - Fax:860-875-9963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2009-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000631106H00000X
101YM0800X
CT0048641041C0700X
CT000365101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT303116OtherMHN