Provider Demographics
NPI:1881754034
Name:ROSE, MICHAEL P (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:P
Last Name:ROSE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 W MCINTOSH ST STE D
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-3463
Mailing Address - Country:US
Mailing Address - Phone:478-457-7447
Mailing Address - Fax:
Practice Address - Street 1:136 W MCINTOSH ST STE D
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-3463
Practice Address - Country:US
Practice Address - Phone:478-457-7447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2439103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical