Provider Demographics
NPI:1326378902
Name:ROSEBERRY, MICHELLE MARIE (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:MARIE
Last Name:ROSEBERRY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 LAKE SAINT LOUIS BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAKE ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-1340
Mailing Address - Country:US
Mailing Address - Phone:636-695-4570
Mailing Address - Fax:636-625-4554
Practice Address - Street 1:2551 BREDELL AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MO
Practice Address - Zip Code:63143-1807
Practice Address - Country:US
Practice Address - Phone:314-302-0909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-05
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009038320111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor