Provider Demographics
NPI:1972766293
Name:LOUIS, ROSE THERESE
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:THERESE
Last Name:LOUIS
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 1:915 NE 125TH ST
Mailing Address - Street 2:106
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-5722
Mailing Address - Country:US
Mailing Address - Phone:305-981-4290
Mailing Address - Fax:305-981-4299
Practice Address - Street 1:915 NE 125TH ST
Practice Address - Street 2:106
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33161-5722
Practice Address - Country:US
Practice Address - Phone:305-981-4290
Practice Address - Fax:305-981-4299
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL693448000Medicaid