Provider Demographics
NPI:1467432856
Name:ROSE, CHARLES FREDERICK (LMFT)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:FREDERICK
Last Name:ROSE
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8333 FOOTHILL BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3154
Mailing Address - Country:US
Mailing Address - Phone:909-579-8205
Mailing Address - Fax:909-579-8250
Practice Address - Street 1:8333 FOOTHILL BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3154
Practice Address - Country:US
Practice Address - Phone:909-579-8205
Practice Address - Fax:909-579-8250
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22451101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA22451OtherPROFESSIONAL LICENSE