Provider Demographics
NPI:1558844555
Name:ROSEBERRY, TATE
Entity Type:Individual
Prefix:
First Name:TATE
Middle Name:
Last Name:ROSEBERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14800 NW CORNELL RD APT 6E
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229
Mailing Address - Country:US
Mailing Address - Phone:707-775-7511
Mailing Address - Fax:
Practice Address - Street 1:1675 SW MARLOW AVENUE, SUITE 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225
Practice Address - Country:US
Practice Address - Phone:971-248-2395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-14
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician