Provider Demographics
NPI:1972237485
Name:ROSE, SHAUN DONOVAN
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:DONOVAN
Last Name:ROSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 CHILES AVE # 7-335
Mailing Address - Street 2:
Mailing Address - City:FORT CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80913-4109
Mailing Address - Country:US
Mailing Address - Phone:912-414-9652
Mailing Address - Fax:
Practice Address - Street 1:10 FARRAGUT AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5626
Practice Address - Country:US
Practice Address - Phone:912-414-9652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-11
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO17-091-3996OtherDRIVERS LICENSE