Provider Demographics
NPI:1083399869
Name:MARY ROSE LCSW, LLC
Entity Type:Organization
Organization Name:MARY ROSE LCSW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:DRAPER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:260-438-4905
Mailing Address - Street 1:1732 S HADLEY RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1458
Mailing Address - Country:US
Mailing Address - Phone:260-438-4905
Mailing Address - Fax:
Practice Address - Street 1:405 AIRPORT NORTH OFFICE PARK
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-6704
Practice Address - Country:US
Practice Address - Phone:260-623-0054
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)