Provider Demographics
NPI:1558661983
Name:ROSE, TAISHA (LAPC)
Entity Type:Individual
Prefix:
First Name:TAISHA
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30601-2244
Mailing Address - Country:US
Mailing Address - Phone:706-389-6789
Mailing Address - Fax:706-227-7249
Practice Address - Street 1:834 HIGHWAY 11 SW
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-6036
Practice Address - Country:US
Practice Address - Phone:706-389-6789
Practice Address - Fax:706-227-7249
Is Sole Proprietor?:No
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC002561101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor