Provider Demographics
NPI:1538404108
Name:ROSE, KRISTI LYN (LMSW)
Entity type:Individual
Prefix:MRS
First Name:KRISTI
Middle Name:LYN
Last Name:ROSE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2055 HARBOR WAY
Mailing Address - Street 2:
Mailing Address - City:KEEGO HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48320-1375
Mailing Address - Country:US
Mailing Address - Phone:248-390-0560
Mailing Address - Fax:
Practice Address - Street 1:409 PLYMOUTH RD STE 270
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1842
Practice Address - Country:US
Practice Address - Phone:248-758-8022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-07
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010705471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical