Provider Demographics
NPI:1073138145
Name:ROSE, THERESE MADDEN
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:MADDEN
Last Name:ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:THERESE
Other - Middle Name:MADDEN
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD, LMFT
Mailing Address - Street 1:5965 SW MENLO DR APT A211
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-4820
Mailing Address - Country:US
Mailing Address - Phone:215-301-9191
Mailing Address - Fax:
Practice Address - Street 1:5965 SW MENLO DR APT A211
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-4820
Practice Address - Country:US
Practice Address - Phone:215-301-9191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-14
Last Update Date:2020-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT25018101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health