Provider Demographics
NPI:1902073158
Name:ROSE, LORETTA M
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:M
Last Name:ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3717 GRANDVIEW DR W
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-2138
Mailing Address - Country:US
Mailing Address - Phone:253-566-5600
Mailing Address - Fax:253-566-5607
Practice Address - Street 1:3717 GRANDVIEW DR W
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-2138
Practice Address - Country:US
Practice Address - Phone:253-566-5600
Practice Address - Fax:253-566-5607
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-15
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA465500G235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200013580AMedicaid