Provider Demographics
NPI:1235103367
Name:ROSE, MARY KAY (LPC)
Entity Type:Individual
Prefix:
First Name:MARY KAY
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3895 SHUTTERLEE MILL RD
Mailing Address - Street 2:
Mailing Address - City:STAUNTON
Mailing Address - State:VA
Mailing Address - Zip Code:24401-6312
Mailing Address - Country:US
Mailing Address - Phone:540-290-3144
Mailing Address - Fax:408-886-0138
Practice Address - Street 1:600 LEE HWY
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:VA
Practice Address - Zip Code:24482-2501
Practice Address - Country:US
Practice Address - Phone:540-290-3144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPRC2000002101YP2500X
VA0701003775101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010135222Medicaid
VA5592438OtherFIRST HEALTH
VA082521MOtherOPTIMA BEHAVIORAL
VA175935OtherANTHEM
VA082521MOtherOPTIMA BEHAVIORAL