Provider Demographics
NPI:1427695295
Name:ROSE, MELANIE
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3005 BOARDWALK ST STE 201
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-5218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3005 BOARDWALK ST STE 201
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-5218
Practice Address - Country:US
Practice Address - Phone:734-222-9277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-28
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X, 156F00000X
MI68011177651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No156F00000XEye and Vision Services ProvidersTechnician/Technologist