Provider Demographics
NPI:1215380787
Name:ROSE, ALICIA (CDPT)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3773 MARTIN WAY E STE 105A
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5048
Mailing Address - Country:US
Mailing Address - Phone:360-688-7312
Mailing Address - Fax:360-688-7318
Practice Address - Street 1:3773 MARTIN WAY E STE 105A
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5048
Practice Address - Country:US
Practice Address - Phone:360-688-7312
Practice Address - Fax:360-688-7318
Is Sole Proprietor?:No
Enumeration Date:2016-07-19
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60463986101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)