Provider Demographics
NPI:1124382239
Name:ROSE, SARA LEAH (MS)
Entity Type:Individual
Prefix:MRS
First Name:SARA
Middle Name:LEAH
Last Name:ROSE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:863 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-3115
Mailing Address - Country:US
Mailing Address - Phone:917-697-0622
Mailing Address - Fax:
Practice Address - Street 1:863 E 17TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-3115
Practice Address - Country:US
Practice Address - Phone:917-697-0622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-03
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY604591951174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist