Provider Demographics
NPI:1295039204
Name:STARK-ROSE, ROSE MELINDA (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROSE
Middle Name:MELINDA
Last Name:STARK-ROSE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 4TH AVE S
Mailing Address - Street 2:SH103
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-4442
Mailing Address - Country:US
Mailing Address - Phone:320-291-3771
Mailing Address - Fax:
Practice Address - Street 1:22 WILSON AVE NE # 110
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56304-0440
Practice Address - Country:US
Practice Address - Phone:320-251-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4670103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling