Provider Demographics
NPI:1588838494
Name:ROSE-BRISSETTE, KATHERINE ANNE
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ANNE
Last Name:ROSE-BRISSETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:ANNE
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:114 ORCHARD LAKE RD
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-2244
Mailing Address - Country:US
Mailing Address - Phone:248-858-7766
Mailing Address - Fax:248-858-8227
Practice Address - Street 1:114 ORCHARD LAKE RD
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-2244
Practice Address - Country:US
Practice Address - Phone:248-858-7766
Practice Address - Fax:248-858-8227
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010891841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical