Provider Demographics
NPI:1558353664
Name:ROSE, STEPHANIE MARIE (DC)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:MARIE
Last Name:ROSE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:MARIE
Other - Last Name:ROSE-GOODMEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16597 MIDDLEBELT RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-3335
Mailing Address - Country:US
Mailing Address - Phone:734-422-2252
Mailing Address - Fax:248-471-0964
Practice Address - Street 1:32595 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MI
Practice Address - Zip Code:48336-3207
Practice Address - Country:US
Practice Address - Phone:248-888-8183
Practice Address - Fax:248-471-0964
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008119111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP108668OtherBCN
MIP108668OtherBCN
MIM97610004Medicare ID - Type Unspecified