Provider Demographics
NPI:1023172616
Name:ROSE, MARCUS WILLIAM (MSP, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARCUS
Middle Name:WILLIAM
Last Name:ROSE
Suffix:
Gender:M
Credentials:MSP, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3626 S BELCHER DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-8225
Mailing Address - Country:US
Mailing Address - Phone:813-966-3591
Mailing Address - Fax:
Practice Address - Street 1:3626 S BELCHER DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-8225
Practice Address - Country:US
Practice Address - Phone:813-966-3591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA5946222Q00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL886346600Medicaid
FL000843100Medicaid
FL000843100Medicaid