Provider Demographics
NPI:1851700280
Name:ROSE, TINA MARIE (PSYD)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:ROSE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 WOODCOCK ST APT O4
Mailing Address - Street 2:
Mailing Address - City:BERTHOUD
Mailing Address - State:CO
Mailing Address - Zip Code:80513-7030
Mailing Address - Country:US
Mailing Address - Phone:970-689-6843
Mailing Address - Fax:
Practice Address - Street 1:1115 ELKTON DR STE 102
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-3597
Practice Address - Country:US
Practice Address - Phone:719-357-6471
Practice Address - Fax:719-434-9811
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-11
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY.0004324103T00000X
OH7190103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist