Provider Demographics
NPI:1427114305
Name:ROSE, MICHAEL BARRY (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BARRY
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 1:6208 SYDNEY RD
Mailing Address - Street 2:SUITE 403
Mailing Address - City:FAIRFAX STATION
Mailing Address - State:VA
Mailing Address - Zip Code:22039-1689
Mailing Address - Country:US
Mailing Address - Phone:301-567-7791
Mailing Address - Fax:301-567-7795
Practice Address - Street 1:6192 OXON HILL RD
Practice Address - Street 2:SUITE 403
Practice Address - City:OXON HILL
Practice Address - State:MD
Practice Address - Zip Code:20745-3143
Practice Address - Country:US
Practice Address - Phone:301-567-7791
Practice Address - Fax:301-567-7795
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD00977103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD115011100Medicaid
MD115011100Medicaid