Provider Demographics
NPI:1376863548
Name:ROSE, TONY G (NCC, LPCC)
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:G
Last Name:ROSE
Suffix:
Gender:M
Credentials:NCC, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2423
Mailing Address - Country:US
Mailing Address - Phone:270-401-4055
Mailing Address - Fax:270-763-9618
Practice Address - Street 1:110 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2423
Practice Address - Country:US
Practice Address - Phone:270-401-4055
Practice Address - Fax:270-763-9618
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-10
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY1113101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional