Provider Demographics
NPI:1588795959
Name:ROSE, ROBERT (LAC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:ROSE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 CALIFORNIA AVENUE
Mailing Address - Street 2:
Mailing Address - City:LIBBY
Mailing Address - State:MT
Mailing Address - Zip Code:59923
Mailing Address - Country:US
Mailing Address - Phone:406-293-7731
Mailing Address - Fax:406-293-2823
Practice Address - Street 1:711 CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:LIBBY
Practice Address - State:MT
Practice Address - Zip Code:59923-1903
Practice Address - Country:US
Practice Address - Phone:406-293-7731
Practice Address - Fax:406-293-2823
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT863101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000076391OtherBLUE CROSS BLUE SHIELD
MT0320372Medicaid