Provider Demographics
NPI:1750853396
Name:ROSE, AUDREY (MA)
Entity Type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1457 S PEORIA ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-2230
Mailing Address - Country:US
Mailing Address - Phone:609-651-1297
Mailing Address - Fax:
Practice Address - Street 1:53 W JACKSON BLVD STE 709
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60604-3475
Practice Address - Country:US
Practice Address - Phone:262-661-2175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health