Provider Demographics
NPI:1518210582
Name:FAWCETT, ROSE
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:FAWCETT
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 1:10100 ELIDA RD
Mailing Address - Street 2:
Mailing Address - City:DELPHOS
Mailing Address - State:OH
Mailing Address - Zip Code:45833-9056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1169 EASTERN PKWY
Practice Address - Street 2:SUITE 3364
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1417
Practice Address - Country:US
Practice Address - Phone:502-742-2336
Practice Address - Fax:502-813-8281
Is Sole Proprietor?:No
Enumeration Date:2012-10-16
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY165258101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional