Provider Demographics
NPI:1720638711
Name:KEVIN ROSE PLLC
Entity Type:Organization
Organization Name:KEVIN ROSE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:734-776-1605
Mailing Address - Street 1:17387 BRODY AVE
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-3417
Mailing Address - Country:US
Mailing Address - Phone:734-776-1605
Mailing Address - Fax:
Practice Address - Street 1:42189 ANN ARBOR RD E
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-4370
Practice Address - Country:US
Practice Address - Phone:734-776-1605
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty