Provider Demographics
NPI:1164480034
Name:WATNE, ROSE M (LCSW)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:M
Last Name:WATNE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5734
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-0734
Mailing Address - Country:US
Mailing Address - Phone:541-955-9698
Mailing Address - Fax:541-955-9698
Practice Address - Street 1:1201--C NE 7TH STREET
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526
Practice Address - Country:US
Practice Address - Phone:541-955-9698
Practice Address - Fax:541-955-9698
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3252101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR275077Medicaid
OR04623Medicare UPIN
OR275077Medicaid