Provider Demographics
NPI:1225119613
Name:MOTEN, ROSE RENEE (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:ROSE
Middle Name:RENEE
Last Name:MOTEN
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:ROSE
Other - Middle Name:
Other - Last Name:MOTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7234 WOODLORE DR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-1388
Mailing Address - Country:US
Mailing Address - Phone:313-717-7673
Mailing Address - Fax:313-557-5317
Practice Address - Street 1:5555 CONNER ST
Practice Address - Street 2:SUITE 3055
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-3448
Practice Address - Country:US
Practice Address - Phone:313-717-7673
Practice Address - Fax:313-557-5317
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011845103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM13990026Medicare ID - Type Unspecified