Provider Demographics
NPI:1629030713
Name:ROSE, ALICE PENNIMAN (LCSW)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:PENNIMAN
Last Name:ROSE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ALICE
Other - Middle Name:MARSH
Other - Last Name:WEISBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:5125 SW MACADAM AVE
Mailing Address - Street 2:STE 145
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239
Mailing Address - Country:US
Mailing Address - Phone:503-231-7854
Mailing Address - Fax:503-231-8153
Practice Address - Street 1:5125 SW MACADAM AVE
Practice Address - Street 2:STE 145
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239
Practice Address - Country:US
Practice Address - Phone:503-231-7854
Practice Address - Fax:503-231-8153
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLCSW23521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical