Provider Demographics
NPI:1689729030
Name:ROSE, ELIZABETH MARIE (PHD LP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARIE
Last Name:ROSE
Suffix:
Gender:F
Credentials:PHD LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 E BURLINGTON ST
Mailing Address - Street 2:SUITES 12 & 14
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52240-1668
Mailing Address - Country:US
Mailing Address - Phone:319-337-3267
Mailing Address - Fax:
Practice Address - Street 1:310 E BURLINGTON ST
Practice Address - Street 2:SUITES 12 & 14
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52240-1668
Practice Address - Country:US
Practice Address - Phone:319-337-3267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00878103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA19649OtherWELLMARK BCBS