Healthcare Provider Details

I. General information

NPI: 1710450283
Provider Name (Legal Business Name): KATHERINE ROSE BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2019
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 MOON STATION DR NW
KENNESAW GA
30144-2759
US

IV. Provider business mailing address

401 HERITAGE DR APT 104
CANTON GA
30114-5697
US

V. Phone/Fax

Practice location:
  • Phone: 770-627-2267
  • Fax:
Mailing address:
  • Phone: 404-512-3680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-19-38892
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: