Provider Demographics
NPI:1235307349
Name:WALLER-ROSE, JULIETTE ELAINE (LICSW)
Entity Type:Individual
Prefix:
First Name:JULIETTE
Middle Name:ELAINE
Last Name:WALLER-ROSE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:ELAINE
Other - Middle Name:
Other - Last Name:WALLER-ROSE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:160 26TH AVE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-6112
Mailing Address - Country:US
Mailing Address - Phone:206-399-4529
Mailing Address - Fax:206-260-1777
Practice Address - Street 1:3300 E UNION ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-3372
Practice Address - Country:US
Practice Address - Phone:206-399-4529
Practice Address - Fax:206-260-1777
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-12
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000058121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8809103Medicare PIN