Provider Demographics
NPI:1154507796
Name:ROSE, GLENN (LSW1887)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:
Last Name:ROSE
Suffix:
Gender:M
Credentials:LSW1887
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1740 E 17TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6375
Mailing Address - Country:US
Mailing Address - Phone:208-529-8832
Mailing Address - Fax:208-522-8725
Practice Address - Street 1:1740 E 17TH ST STE B
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6375
Practice Address - Country:US
Practice Address - Phone:208-529-8832
Practice Address - Fax:208-522-8725
Is Sole Proprietor?:No
Enumeration Date:2008-01-14
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLSW1887104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker