Provider Demographics
NPI:1467807016
Name:ROSE, CONNOR LAWRENCE
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:LAWRENCE
Last Name:ROSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 HOSPITAL LOOP
Mailing Address - Street 2:FAIRCHILD AFB
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201
Mailing Address - Country:US
Mailing Address - Phone:509-247-2731
Mailing Address - Fax:
Practice Address - Street 1:701 HOSPITAL LOOP
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201
Practice Address - Country:US
Practice Address - Phone:509-247-2731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-02
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
VA0810007422103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health