Provider Demographics
NPI:1417142456
Name:ROSE, STEPHANIE F (LCSW)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:F
Last Name:ROSE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 KAVANAUGH BLVD STE 5
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-3991
Mailing Address - Country:US
Mailing Address - Phone:501-663-8990
Mailing Address - Fax:
Practice Address - Street 1:2601 KAVANAUGH BLVD STE 5
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-3991
Practice Address - Country:US
Practice Address - Phone:501-663-8990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2019-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2486-M104100000X
171M00000X
AR3529-C101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR116399726Medicaid