MEDICARE: DR. TERESA BETH ROSE LICENSEDPSYCHOLOGIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	2000167702	MO
2	103T00000X	Psychologist	1262	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6183141	OTHER	MO	UHC UBH
2	30786016	OTHER	MO	BCBS

General Provider Information

NPI Number	:	1326069030
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TERESA BETH ROSE LICENSEDPSYCHOLOGIST

Provider Business Mailing Address
First Line	:	3965 W 83RD STREET #182
Second Line	:
City	:	PRAIRIE VILLAGE
State	:	KS
Zip	:	66208
Country	:	US
Telephone Number	:	816-363-9500
Fax Number	:

Provider Business Practice Location Address
First Line	:	4200 SOMERSET DR
Second Line	:	SUITE 239
City	:	PRAIRIE VILLAGE
State	:	KS
Zip	:	66208-5217
Country	:	US
Telephone Number	:	816-363-9500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2006
Last Update Date	:	09/17/2020

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