Provider Demographics
NPI:1639543218
Name:ROSE, SARA ROLAND (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SARA
Middle Name:ROLAND
Last Name:ROSE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 CREEKSTONE RDG
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-3732
Mailing Address - Country:US
Mailing Address - Phone:404-532-9246
Mailing Address - Fax:
Practice Address - Street 1:240 CREEKSTONE RDG
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-3732
Practice Address - Country:US
Practice Address - Phone:404-532-9246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-19
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY004066103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical