Provider Demographics
NPI:1508145897
Name:ROSA, TERI M (LPC)
Entity type:Individual
Prefix:
First Name:TERI
Middle Name:M
Last Name:ROSA
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:TERI
Other - Middle Name:M
Other - Last Name:ROSA-SOUTHWORTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:201 MULHOLLAND ST
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708-7693
Mailing Address - Country:US
Mailing Address - Phone:989-895-2300
Mailing Address - Fax:989-497-1545
Practice Address - Street 1:201 MULHOLLAND ST
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-7693
Practice Address - Country:US
Practice Address - Phone:989-895-2300
Practice Address - Fax:989-497-1545
Is Sole Proprietor?:No
Enumeration Date:2011-08-04
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401006345101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional