Provider Demographics
NPI:1457601320
Name:ROSE, BRANDON (MED)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:ROSE
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 SW 83RD AVE
Mailing Address - Street 2:
Mailing Address - City:OKEECHOBEE
Mailing Address - State:FL
Mailing Address - Zip Code:34974-3361
Mailing Address - Country:US
Mailing Address - Phone:863-532-1786
Mailing Address - Fax:
Practice Address - Street 1:314 NW 5TH ST STE 314
Practice Address - Street 2:
Practice Address - City:OKEECHOBEE
Practice Address - State:FL
Practice Address - Zip Code:34972-2565
Practice Address - Country:US
Practice Address - Phone:304-784-6689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-18
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health