Provider Demographics
NPI:1710450283
Name:ROSE, KATHERINE (BCBA)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 HERITAGE DR APT 104
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-5697
Mailing Address - Country:US
Mailing Address - Phone:404-512-3680
Mailing Address - Fax:
Practice Address - Street 1:2110 MOON STATION DR NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-2759
Practice Address - Country:US
Practice Address - Phone:770-627-2267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-08
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
GA1-19-38892103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician