Provider Demographics
NPI:1801927066
Name:HEISE, ROSE MARY (MA, CAADC, LPN)
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:MARY
Last Name:HEISE
Suffix:
Gender:F
Credentials:MA, CAADC, LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-4025
Mailing Address - Country:US
Mailing Address - Phone:517-740-1351
Mailing Address - Fax:
Practice Address - Street 1:1500 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-4025
Practice Address - Country:US
Practice Address - Phone:517-740-1351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1-00244101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI750910682OtherBCBSM