Provider Demographics
NPI:1285222455
Name:ROSE, MERLINDA CARMEN (LSAA)
Entity Type:Individual
Prefix:
First Name:MERLINDA
Middle Name:CARMEN
Last Name:ROSE
Suffix:
Gender:F
Credentials:LSAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 QUINCY ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-1257
Mailing Address - Country:US
Mailing Address - Phone:505-550-1306
Mailing Address - Fax:
Practice Address - Street 1:146 QUINCY ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-1257
Practice Address - Country:US
Practice Address - Phone:505-550-1306
Practice Address - Fax:844-434-8055
Is Sole Proprietor?:No
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCSA0214801101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)