Provider Demographics
NPI:1386199537
Name:ROSE, MEGAN
Entity Type:Individual
Prefix:
First Name:MEGAN
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 1:2396 W NEBRASKA AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-3111
Mailing Address - Country:US
Mailing Address - Phone:309-676-6305
Mailing Address - Fax:
Practice Address - Street 1:2396 W NEBRASKA AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-3111
Practice Address - Country:US
Practice Address - Phone:309-676-6305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-17
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health