Provider Demographics
NPI:1114153715
Name:ROSE, KEN TOMAS
Entity Type:Individual
Prefix:
First Name:KEN
Middle Name:TOMAS
Last Name:ROSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33405 8TH AVE S UNIT 200
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6639
Mailing Address - Country:US
Mailing Address - Phone:253-409-4148
Mailing Address - Fax:253-661-8644
Practice Address - Street 1:325 E PIONEER
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3265
Practice Address - Country:US
Practice Address - Phone:253-697-8400
Practice Address - Fax:253-697-3730
Is Sole Proprietor?:No
Enumeration Date:2009-06-09
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60146768101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health