Provider Demographics
NPI:1316225212
Name:ROSE GARDEN CLINIC, LLC
Entity Type:Organization
Organization Name:ROSE GARDEN CLINIC, LLC
Other - Org Name:ROSENQUIST COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LEAD COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:PAUL CHRISTIAN
Authorized Official - Last Name:ROSENQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC, LBP
Authorized Official - Phone:580-429-2700
Mailing Address - Street 1:PO BOX 181
Mailing Address - Street 2:
Mailing Address - City:CACHE
Mailing Address - State:OK
Mailing Address - Zip Code:73527-0181
Mailing Address - Country:US
Mailing Address - Phone:580-429-2700
Mailing Address - Fax:580-429-2701
Practice Address - Street 1:509 WEST C AVE
Practice Address - Street 2:
Practice Address - City:CACHE
Practice Address - State:OK
Practice Address - Zip Code:73527
Practice Address - Country:US
Practice Address - Phone:580-429-2700
Practice Address - Fax:580-429-2701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-26
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0109101YM0800X
OKCERT. SEX OFF TREATM101YM0800X
OK2757101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200334980AMedicaid