Provider Demographics
NPI:1437411279
Name:ROSE, IRIS B
Entity Type:Individual
Prefix:MS
First Name:IRIS
Middle Name:B
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 1:101 CLARK ST APT 14H
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-7801
Mailing Address - Country:US
Mailing Address - Phone:917-771-3737
Mailing Address - Fax:
Practice Address - Street 1:101 CLARK ST APT 14H
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-7801
Practice Address - Country:US
Practice Address - Phone:917-771-3737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-07
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY16656252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY16656OtherEARLY INTERVENTION SERVICE COORDINATOR