Provider Demographics
NPI:1265815633
Name:ROSE, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:
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 14754
Mailing Address - Street 2:
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02914-0754
Mailing Address - Country:US
Mailing Address - Phone:508-292-0000
Mailing Address - Fax:
Practice Address - Street 1:1023 POST RD
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02888-3363
Practice Address - Country:US
Practice Address - Phone:508-292-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-03
Last Update Date:2015-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICSW017941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical