Provider Demographics
NPI:1346209152
Name:ROSE, MARY ANN (LISW-S)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:ROSE
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 COOK RD
Mailing Address - Street 2:SUIE 400
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-9600
Mailing Address - Country:US
Mailing Address - Phone:513-228-7800
Mailing Address - Fax:513-695-2952
Practice Address - Street 1:975 KINGSVIEW DR BLDG A
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036
Practice Address - Country:US
Practice Address - Phone:513-228-7800
Practice Address - Fax:513-228-7846
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-5934-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
11749002OtherCAQH #
000000246058OtherANTHEM PIN
OH2016071Medicare PIN