Provider Demographics
NPI:1750743373
Name:ROSE, STEPHANIE DIANNE (PHD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DIANNE
Last Name:ROSE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CRAWFORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47933-1106
Mailing Address - Country:US
Mailing Address - Phone:937-532-4914
Mailing Address - Fax:
Practice Address - Street 1:1480 DARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-2007
Practice Address - Country:US
Practice Address - Phone:765-362-2852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-23
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99072078A103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling