Provider Demographics
NPI:1326372673
Name:ROSE, STEPHANIE HANEY (LICSW)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:HANEY
Last Name:ROSE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 RYE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-0000
Mailing Address - Country:US
Mailing Address - Phone:802-654-7607
Mailing Address - Fax:802-654-9155
Practice Address - Street 1:27 RYE CIRCLE
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-0000
Practice Address - Country:US
Practice Address - Phone:802-654-7607
Practice Address - Fax:802-654-9155
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-18
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA415598101YS0200X
MA1152541041C0700X
VT08900714811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1018309Medicaid