Provider Demographics
NPI:1053618322
Name:ROSEBERRY, MARK OWEN (MA, CCC-SLP)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:OWEN
Last Name:ROSEBERRY
Suffix:
Gender:M
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9351 HIGHWAY 370
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38663-7310
Mailing Address - Country:US
Mailing Address - Phone:662-882-3610
Mailing Address - Fax:
Practice Address - Street 1:9351 HIGHWAY 370
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:MS
Practice Address - Zip Code:38663-7310
Practice Address - Country:US
Practice Address - Phone:662-882-3610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-22
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS2488235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist