Healthcare Provider Details

I. General information

NPI: 1417618372
Provider Name (Legal Business Name): SENTA ROSE M.A., LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2022
Last Update Date: 05/16/2022
Certification Date: 05/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 N GRAND RIVER AVE SUITE A
OKEMOS MI
48864
US

IV. Provider business mailing address

2222 N GRAND RIVER AVE SUITE A
OKEMOS MI
48864
US

V. Phone/Fax

Practice location:
  • Phone: 734-274-9571
  • Fax:
Mailing address:
  • Phone: 734-274-9571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number6301007406
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6361003880
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: