Provider Demographics
NPI:1316478878
Name:MILLER ROSE, KATHRYN ELAINE
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ELAINE
Last Name:MILLER ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:E
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1207 LAKESIDE LN
Mailing Address - Street 2:
Mailing Address - City:MAHOMET
Mailing Address - State:IL
Mailing Address - Zip Code:61853-9767
Mailing Address - Country:US
Mailing Address - Phone:217-840-5455
Mailing Address - Fax:
Practice Address - Street 1:1207 LAKESIDE LN
Practice Address - Street 2:
Practice Address - City:MAHOMET
Practice Address - State:IL
Practice Address - Zip Code:61853-9767
Practice Address - Country:US
Practice Address - Phone:217-840-5455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-25
Last Update Date:2017-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070.005074OtherSTATE PT LICENCE