Provider Demographics
NPI:1477250082
Name:ROSE, LORI M
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:M
Last Name:ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:N SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-2370
Mailing Address - Country:US
Mailing Address - Phone:315-415-0308
Mailing Address - Fax:
Practice Address - Street 1:113 CHURCH ST
Practice Address - Street 2:
Practice Address - City:N SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-2370
Practice Address - Country:US
Practice Address - Phone:315-415-0308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health