Provider Demographics
NPI:1538271754
Name:ROSE, ELIZABETH (LLP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9460 S SAGINAW RD
Mailing Address - Street 2:STE D
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-8207
Mailing Address - Country:US
Mailing Address - Phone:810-424-2007
Mailing Address - Fax:810-743-1099
Practice Address - Street 1:8435 HOLLY RD
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-1812
Practice Address - Country:US
Practice Address - Phone:810-424-2400
Practice Address - Fax:810-579-7222
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011940103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N75420Medicare PIN