Provider Demographics
NPI:1417590506
Name:ROSE, KRISTIN A (DT)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:A
Last Name:ROSE
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:A
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DT
Mailing Address - Street 1:701 W CHURCH ST APT 1
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3393
Mailing Address - Country:US
Mailing Address - Phone:217-621-7129
Mailing Address - Fax:
Practice Address - Street 1:1304 W BRADLEY AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-2035
Practice Address - Country:US
Practice Address - Phone:217-356-9176
Practice Address - Fax:217-398-7137
Is Sole Proprietor?:No
Enumeration Date:2019-10-22
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1801952817Medicaid