Provider Demographics
NPI:1811204100
Name:ROWE, MYA ROSE (CMT)
Entity Type:Individual
Prefix:MRS
First Name:MYA
Middle Name:ROSE
Last Name:ROWE
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:NEILLSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54456-1941
Mailing Address - Country:US
Mailing Address - Phone:715-937-3115
Mailing Address - Fax:
Practice Address - Street 1:154 E 5TH ST
Practice Address - Street 2:
Practice Address - City:NEILLSVILLE
Practice Address - State:WI
Practice Address - Zip Code:54456-1941
Practice Address - Country:US
Practice Address - Phone:715-937-3115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4574-046174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist