Provider Demographics
NPI:1073044830
Name:ROSE, CARLY (QMHA, THW-YSS, CPC)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:QMHA, THW-YSS, CPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2411 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-5824
Mailing Address - Country:US
Mailing Address - Phone:541-603-6965
Mailing Address - Fax:
Practice Address - Street 1:2411 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-5824
Practice Address - Country:US
Practice Address - Phone:541-603-6965
Practice Address - Fax:541-682-3276
Is Sole Proprietor?:No
Enumeration Date:2017-03-23
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21-QMHA-R-1845171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator