Provider Demographics
NPI:1053884536
Name:ROSE, MICHELLE TAKEMI (BCBA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:TAKEMI
Last Name:ROSE
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:TAKEMI
Other - Last Name:ROWLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BCBA
Mailing Address - Street 1:5051 LA JOLLA BLVD UNIT 202
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-1713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:501 W BROADWAY STE 800
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-3546
Practice Address - Country:US
Practice Address - Phone:877-418-2978
Practice Address - Fax:866-500-2186
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-07
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-18-34091103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst