Provider Demographics
NPI:1093937690
Name:ROSE, KATHY (LMT)
Entity Type:Individual
Prefix:MS
First Name:KATHY
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 S MAIN ST
Mailing Address - Street 2:#3
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-3151
Mailing Address - Country:US
Mailing Address - Phone:315-781-2560
Mailing Address - Fax:
Practice Address - Street 1:751 PRE EMPTION RD
Practice Address - Street 2:SUITE 2
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-1335
Practice Address - Country:US
Practice Address - Phone:315-789-8212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014450225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist