Provider Demographics
NPI:1265862775
Name:PEARSON, ROSE (LPC)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:PEARSON
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 1:100 AUGUSTA CT APT A
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:GA
Mailing Address - Zip Code:31763-2976
Mailing Address - Country:US
Mailing Address - Phone:404-401-6271
Mailing Address - Fax:
Practice Address - Street 1:2121A BELLEVUE RD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2998
Practice Address - Country:US
Practice Address - Phone:478-272-1190
Practice Address - Fax:478-275-6649
Is Sole Proprietor?:No
Enumeration Date:2013-11-19
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007269101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300030912AMedicaid
GA000606284HMedicaid
GAGRP2130Medicare UPIN