Provider Demographics
NPI:1821677816
Name:GROSE, MICHELLE ROSE (LMT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ROSE
Last Name:GROSE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 E MONROE AVE APT 214
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22301-3024
Mailing Address - Country:US
Mailing Address - Phone:315-542-2148
Mailing Address - Fax:
Practice Address - Street 1:625 E MONROE AVE APT 214
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22301-3024
Practice Address - Country:US
Practice Address - Phone:315-542-2148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-06
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019016096225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist