Provider Demographics
NPI:1326494592
Name:ROSE, MARK L (CDP, BA, ICRC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:L
Last Name:ROSE
Suffix:
Gender:M
Credentials:CDP, BA, ICRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 36TH AVE SW
Mailing Address - Street 2:#412
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98126-2794
Mailing Address - Country:US
Mailing Address - Phone:206-419-5664
Mailing Address - Fax:
Practice Address - Street 1:4600 36TH AVE SW
Practice Address - Street 2:#412
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98126-2794
Practice Address - Country:US
Practice Address - Phone:206-419-5664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-06
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP 60073428101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)