Provider Demographics
NPI:1134502933
Name:ROSE, MICHAEL DEAN (MED)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DEAN
Last Name:ROSE
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1127 WARD ST
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-5047
Mailing Address - Country:US
Mailing Address - Phone:360-388-6452
Mailing Address - Fax:
Practice Address - Street 1:320 6TH ST
Practice Address - Street 2:
Practice Address - City:RAYMOND
Practice Address - State:WA
Practice Address - Zip Code:98577-2503
Practice Address - Country:US
Practice Address - Phone:360-915-6868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WABA61483912103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst