Provider Demographics
NPI:1265448104
Name:ROSE, RACHELLE A (PHD)
Entity Type:Individual
Prefix:
First Name:RACHELLE
Middle Name:A
Last Name:ROSE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 E 200 S
Mailing Address - Street 2:NORTHERN UTAH MENTAL COUNSELING
Mailing Address - City:CLEARFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84015-1047
Mailing Address - Country:US
Mailing Address - Phone:801-779-0095
Mailing Address - Fax:801-779-0255
Practice Address - Street 1:49 E 200 S
Practice Address - Street 2:NORTHERN UTAH MENTAL COUNSELING
Practice Address - City:CLEARFIELD
Practice Address - State:UT
Practice Address - Zip Code:84015-1047
Practice Address - Country:US
Practice Address - Phone:801-779-0095
Practice Address - Fax:801-779-0255
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5712578-2501-2014092103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000060905Medicare PIN