Provider Demographics
NPI:1861760563
Name:ROSE, LAURENCE (MA MFT)
Entity type:Individual
Prefix:MRS
First Name:LAURENCE
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:MA MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6662 SMOKE TREE AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91377
Mailing Address - Country:US
Mailing Address - Phone:818-851-1091
Mailing Address - Fax:
Practice Address - Street 1:6652 SMOKE TREE AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:CA
Practice Address - Zip Code:91377-1303
Practice Address - Country:US
Practice Address - Phone:818-851-1091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-08
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
102L00000X
CA83317106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst