Provider Demographics
NPI:1437663069
Name:ROSE, LORRAINE (CDCA)
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:LORRAINE
Other - Middle Name:
Other - Last Name:CIPRIANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CDCA
Mailing Address - Street 1:4510 DORR ST # MS 840
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-4040
Mailing Address - Country:US
Mailing Address - Phone:419-383-5695
Mailing Address - Fax:419-383-3031
Practice Address - Street 1:3125 TRANSVERSE DR
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-8008
Practice Address - Country:US
Practice Address - Phone:419-841-7701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-17
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.1637011041C0700X
OH163701101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0289273Medicaid