Provider Demographics
NPI:1558661447
Name:ROSE, KRISTIN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 HALL JOHNSON RD
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-7810
Mailing Address - Country:US
Mailing Address - Phone:682-564-5588
Mailing Address - Fax:817-428-9885
Practice Address - Street 1:1215 HALL JOHNSON RD
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-7810
Practice Address - Country:US
Practice Address - Phone:682-564-5588
Practice Address - Fax:817-428-9885
Is Sole Proprietor?:No
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34734103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical