Provider Demographics
NPI:1598311888
Name:ROSE, KERI LYNN
Entity Type:Individual
Prefix:
First Name:KERI
Middle Name:LYNN
Last Name:ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KERI
Other - Middle Name:LYNN
Other - Last Name:KLEINHOLZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10108 E THEOREM DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-9654
Mailing Address - Country:US
Mailing Address - Phone:480-636-0240
Mailing Address - Fax:
Practice Address - Street 1:4132 E ADOBE ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-5110
Practice Address - Country:US
Practice Address - Phone:480-636-0240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA109282355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language AssistantGroup - Single Specialty