Provider Demographics
NPI:1467653097
Name:ROSE, JUDITH ALICIA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:ALICIA
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 1:429 MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:EAST QUOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11942-3919
Mailing Address - Country:US
Mailing Address - Phone:631-653-8664
Mailing Address - Fax:631-653-3934
Practice Address - Street 1:429 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:EAST QUOGUE
Practice Address - State:NY
Practice Address - Zip Code:11942-3919
Practice Address - Country:US
Practice Address - Phone:631-653-8664
Practice Address - Fax:631-653-3934
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRO46867-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNOC651Medicare ID - Type Unspecified