Provider Demographics
NPI:1578870127
Name:MESA, ROSE (LMFT)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:MESA
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1745 POCATELLO CREEK RD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2308
Mailing Address - Country:US
Mailing Address - Phone:208-233-9383
Mailing Address - Fax:
Practice Address - Street 1:1745 POCATELLO CREEK RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2308
Practice Address - Country:US
Practice Address - Phone:208-233-9383
Practice Address - Fax:208-233-2707
Is Sole Proprietor?:No
Enumeration Date:2010-09-02
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMFT 4384106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist