Provider Demographics
NPI:1770042913
Name:COLEY, ROSA MARILYN JR
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:MARILYN
Last Name:COLEY
Suffix:JR
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4157 JUDD AVE
Mailing Address - Street 2:
Mailing Address - City:SCHILLER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60176-1813
Mailing Address - Country:US
Mailing Address - Phone:312-206-5639
Mailing Address - Fax:
Practice Address - Street 1:51 W SCHAUMBURG RD
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60194-3506
Practice Address - Country:US
Practice Address - Phone:847-607-1113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-18
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
IL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician