Provider Demographics
NPI:1114101839
Name:ROSE, STACY ERIN (PLMHP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:ERIN
Last Name:ROSE
Suffix:
Gender:F
Credentials:PLMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7829 CHICAGO PLZ
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-3653
Mailing Address - Country:US
Mailing Address - Phone:402-393-0163
Mailing Address - Fax:402-393-7187
Practice Address - Street 1:100 WEST 29TH ST
Practice Address - Street 2:SUITE 319
Practice Address - City:SOUTH SIOUX
Practice Address - State:NE
Practice Address - Zip Code:68776
Practice Address - Country:US
Practice Address - Phone:402-494-4904
Practice Address - Fax:402-494-1210
Is Sole Proprietor?:No
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE8481101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor