Provider Demographics
NPI:1083502850
Name:ROSE, NICHOLAS (DPT)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:ROSE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2470 LONGSTONE LN STE A
Mailing Address - Street 2:
Mailing Address - City:MARRIOTTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21104-1516
Mailing Address - Country:US
Mailing Address - Phone:410-982-6251
Mailing Address - Fax:410-982-6263
Practice Address - Street 1:12447 CLARKSVILLE PIKE STE 2C
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21029-1243
Practice Address - Country:US
Practice Address - Phone:410-982-6251
Practice Address - Fax:410-982-6263
Is Sole Proprietor?:No
Enumeration Date:2025-06-27
Last Update Date:2025-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD30473225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist