Provider Demographics
NPI:1023506284
Name:ROSE, MELISSA (DSP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:DSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 NEAL ST
Mailing Address - Street 2:
Mailing Address - City:GARDINER
Mailing Address - State:ME
Mailing Address - Zip Code:04345-2005
Mailing Address - Country:US
Mailing Address - Phone:207-557-4686
Mailing Address - Fax:
Practice Address - Street 1:46 NEAL ST
Practice Address - Street 2:
Practice Address - City:GARDINER
Practice Address - State:ME
Practice Address - Zip Code:04345
Practice Address - Country:US
Practice Address - Phone:207-557-4686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-24
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities