Individual
KATHRYN ELAINE MILLER ROSE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
1207 LAKESIDE LN, MAHOMET, IL 61853-9767
(217) 840-5455
Mailing address
1207 LAKESIDE LN, MAHOMET, IL 61853-9767
(217) 840-5455
Taxonomy
Speciality
Code
Description
License number
State
251C00000X
Developmentally Disabled Services Day Training Agency
Primary
—
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
070.005074
STATE PT LICENCE
IL
Enumeration date
03/25/2017
Last updated
03/25/2017
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