Provider Demographics
NPI:1407847403
Name:ROSE, NETTIE LYNNE (LISW LADAC)
Entity Type:Individual
Prefix:MRS
First Name:NETTIE
Middle Name:LYNNE
Last Name:ROSE
Suffix:
Gender:F
Credentials:LISW LADAC
Other - Prefix:MS
Other - First Name:NETTIE
Other - Middle Name:LYNNE
Other - Last Name:CLEGG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1610 SAN PEDRO NE #A
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110
Mailing Address - Country:US
Mailing Address - Phone:225-936-7242
Mailing Address - Fax:
Practice Address - Street 1:1610 SAN PEDRO NE #A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110
Practice Address - Country:US
Practice Address - Phone:505-265-0753
Practice Address - Fax:505-268-5722
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4198101YA0400X
NMI4453101YM0800X
NMC-4453101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM37376764Medicaid