Provider Demographics
NPI:1104136654
Name:ROSE, KIRSTEN (MS)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 POTRERO ST
Mailing Address - Street 2:STE C
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-7610
Mailing Address - Country:US
Mailing Address - Phone:831-425-9500
Mailing Address - Fax:
Practice Address - Street 1:317 POTRERO ST
Practice Address - Street 2:STE C
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-7610
Practice Address - Country:US
Practice Address - Phone:831-425-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18813225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist