Provider Demographics
NPI:1609021658
Name:ROSE, TERESA GAIL
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:GAIL
Last Name:ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2527 LAKE DR S
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-6482
Mailing Address - Country:US
Mailing Address - Phone:217-228-2929
Mailing Address - Fax:
Practice Address - Street 1:2527 LAKE DR S
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62305-6482
Practice Address - Country:US
Practice Address - Phone:217-228-2929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-18
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist