Provider Demographics
NPI:1346386695
Name:CLARK, ROSE
Entity Type:Individual
Prefix:MRS
First Name:ROSE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:ROSE
Other - Middle Name:
Other - Last Name:GARTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:330 W LEXINGTON AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516
Mailing Address - Country:US
Mailing Address - Phone:574-293-5991
Mailing Address - Fax:574-293-5429
Practice Address - Street 1:108 N MAIN ST
Practice Address - Street 2:SUITE 500
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601
Practice Address - Country:US
Practice Address - Phone:574-246-1244
Practice Address - Fax:574-246-1250
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33004605A104100000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist