Provider Demographics
NPI:1053720607
Name:ROSE, ANTOINETTE (MED MHC)
Entity type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:MED MHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 GLENDALE ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02125-2404
Mailing Address - Country:US
Mailing Address - Phone:857-220-7193
Mailing Address - Fax:
Practice Address - Street 1:500 VICTORY RD
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02171-3139
Practice Address - Country:US
Practice Address - Phone:617-847-1950
Practice Address - Fax:617-774-1490
Is Sole Proprietor?:No
Enumeration Date:2014-08-07
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health