Provider Demographics
NPI:1265049902
Name:ROSE, ERIN L (ATC)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:L
Last Name:ROSE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:L
Other - Last Name:GODDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:512 BRITTON LN
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-8801
Mailing Address - Country:US
Mailing Address - Phone:209-418-9543
Mailing Address - Fax:
Practice Address - Street 1:510 NW LARRY ST
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-3584
Practice Address - Country:US
Practice Address - Phone:509-332-1551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-27
Last Update Date:2020-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAA1609768442255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer