Provider Demographics
NPI:1245534429
Name:ROSE, AMY M (PSYD)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:M
Last Name:ROSE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 E MISSOURI AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2446
Mailing Address - Country:US
Mailing Address - Phone:602-274-1928
Mailing Address - Fax:
Practice Address - Street 1:1515 E MISSOURI AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2446
Practice Address - Country:US
Practice Address - Phone:602-274-1928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-03
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3342581103TS0200X
AZ4275103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool