Provider Demographics
NPI:1073990982
Name:SOUVERAIN, ROSE
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:SOUVERAIN
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 1:404 TRANQUILLE OAKS DR
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-1402
Mailing Address - Country:US
Mailing Address - Phone:321-460-4138
Mailing Address - Fax:321-558-3055
Practice Address - Street 1:404 TRANQUILLE OAKS DR
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-1402
Practice Address - Country:US
Practice Address - Phone:321-460-4138
Practice Address - Fax:321-558-3055
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-29
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906125320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness