Provider Demographics
NPI:1174783021
Name:ROSES, LORI M (AUD)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:M
Last Name:ROSES
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 530062
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-0062
Mailing Address - Country:US
Mailing Address - Phone:843-695-6071
Mailing Address - Fax:843-569-5881
Practice Address - Street 1:3495 IRON HORSE RD STE B
Practice Address - Street 2:
Practice Address - City:LADSON
Practice Address - State:SC
Practice Address - Zip Code:29456-4319
Practice Address - Country:US
Practice Address - Phone:843-258-5060
Practice Address - Fax:843-492-4712
Is Sole Proprietor?:No
Enumeration Date:2008-06-13
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YA00058800231H00000X
NJ25MG00091600237600000X
SC4104231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA1994Medicaid