Provider Demographics
NPI:1972846434
Name:ROSE, MICHELE (MSED SBL)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:MSED SBL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 POND VW
Mailing Address - Street 2:SUITE 102A
Mailing Address - City:CASTLETON
Mailing Address - State:NY
Mailing Address - Zip Code:12033-9750
Mailing Address - Country:US
Mailing Address - Phone:518-477-6072
Mailing Address - Fax:518-477-6074
Practice Address - Street 1:2500 POND VW
Practice Address - Street 2:SUITE 102A
Practice Address - City:CASTLETON
Practice Address - State:NY
Practice Address - Zip Code:12033-9750
Practice Address - Country:US
Practice Address - Phone:518-477-6072
Practice Address - Fax:518-477-6074
Is Sole Proprietor?:No
Enumeration Date:2013-04-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY-1390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program