Provider Demographics
NPI:1629401344
Name:ROSE, KIMBERLEY ERIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLEY
Middle Name:ERIN
Last Name:ROSE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KIMBERLEY
Other - Middle Name:ERIN
Other - Last Name:BREWER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:2800 L ST
Practice Address - Street 2:SUITE 500
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5616
Practice Address - Country:US
Practice Address - Phone:916-454-6847
Practice Address - Fax:916-454-6852
Is Sole Proprietor?:No
Enumeration Date:2013-08-16
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25898103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist