Provider Demographics
NPI:1376090480
Name:ROSE, MARTIN (LCSW)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
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 1:231 LAFFERTY ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-0740
Mailing Address - Country:US
Mailing Address - Phone:919-273-5265
Mailing Address - Fax:
Practice Address - Street 1:231 LAFFERTY ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-0740
Practice Address - Country:US
Practice Address - Phone:919-273-5265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-07
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0108531041C0700X
NCC0122291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical