Provider Demographics
NPI:1619040375
Name:COLLEY, ROSE L (LCSW)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:L
Last Name:COLLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5339 DIDESSE DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4306
Mailing Address - Country:US
Mailing Address - Phone:225-769-7581
Mailing Address - Fax:225-769-7540
Practice Address - Street 1:5339 DIDESSE DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4306
Practice Address - Country:US
Practice Address - Phone:225-769-7581
Practice Address - Fax:225-769-7540
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA28031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1186198Medicaid
LA5X790Medicare ID - Type Unspecified