Provider Demographics
NPI:1871263574
Name:ROSE, DEBRA JEAN
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:JEAN
Last Name:ROSE
Suffix:
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 1:55700 M 43
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:MI
Mailing Address - Zip Code:49013-9566
Mailing Address - Country:US
Mailing Address - Phone:269-427-8909
Mailing Address - Fax:
Practice Address - Street 1:55700 M 43
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:MI
Practice Address - Zip Code:49013-9566
Practice Address - Country:US
Practice Address - Phone:269-427-8909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF800016057253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency