Provider Demographics
NPI:1366637365
Name:ROSE, LARRY JAMES (LCSW)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:JAMES
Last Name:ROSE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 STATE LINE RD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-7204
Mailing Address - Country:US
Mailing Address - Phone:423-542-4245
Mailing Address - Fax:423-542-4369
Practice Address - Street 1:2600 STATE LINE RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-7204
Practice Address - Country:US
Practice Address - Phone:423-542-4245
Practice Address - Fax:423-542-4369
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW00000004841041C0700X
VA09040034611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical