Provider Demographics
NPI:1063445294
Name:MICHI ROSE INC
Entity Type:Organization
Organization Name:MICHI ROSE INC
Other - Org Name:MICHI ROSE PHD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHI
Authorized Official - Middle Name:ISHIDA
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:269-353-3380
Mailing Address - Street 1:5464 HOLIDAY TERRACE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009
Mailing Address - Country:US
Mailing Address - Phone:269-353-3380
Mailing Address - Fax:269-353-3380
Practice Address - Street 1:5464 HOLIDAY TERRACE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009
Practice Address - Country:US
Practice Address - Phone:269-353-3380
Practice Address - Fax:269-353-3380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801071154104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ON65670Medicare ID - Type Unspecified