Provider Demographics
NPI:1831743921
Name:ROSE, ROBIN L
Entity type:Individual
Prefix:
First Name:ROBIN
Middle Name:L
Last Name:ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 DEFOE ST APT A
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-2452
Mailing Address - Country:US
Mailing Address - Phone:406-880-3583
Mailing Address - Fax:
Practice Address - Street 1:206 S 3RD ST W
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-2524
Practice Address - Country:US
Practice Address - Phone:405-926-1881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-28
Last Update Date:2019-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLMT-LMT-LIC-16434225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist