Provider Demographics
NPI:1679348858
Name:ROSE, WESTON LEWIS
Entity type:Individual
Prefix:
First Name:WESTON
Middle Name:LEWIS
Last Name:ROSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:871 W BEAVER CREEK BLVD # C23
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CO
Mailing Address - Zip Code:81620-7457
Mailing Address - Country:US
Mailing Address - Phone:920-246-7907
Mailing Address - Fax:
Practice Address - Street 1:210 EDWARDS VILLAGE BLVD
Practice Address - Street 2:
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632-5277
Practice Address - Country:US
Practice Address - Phone:970-977-9154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-17
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician