Provider Demographics
NPI:1518612597
Name:ROOSE, KRISTINA (LSW)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:ROOSE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 N DELAWARE AVE STE 600
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-4339
Mailing Address - Country:US
Mailing Address - Phone:215-496-0707
Mailing Address - Fax:
Practice Address - Street 1:1080 N DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19125-4330
Practice Address - Country:US
Practice Address - Phone:215-496-0707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW137790101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health