Provider Demographics
NPI:1487859773
Name:ROSE, GEORGIA GALE (LADC)
Entity Type:Individual
Prefix:MS
First Name:GEORGIA
Middle Name:GALE
Last Name:ROSE
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:279 MITCHELL RD
Mailing Address - Street 2:
Mailing Address - City:CAPE ELIZABETH
Mailing Address - State:ME
Mailing Address - Zip Code:04107
Mailing Address - Country:US
Mailing Address - Phone:207-899-1285
Mailing Address - Fax:
Practice Address - Street 1:4 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LIMERICK
Practice Address - State:ME
Practice Address - Zip Code:04048-0091
Practice Address - Country:US
Practice Address - Phone:207-793-4933
Practice Address - Fax:207-793-4909
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)