Provider Demographics
NPI:1629198148
Name:ROSE, MARSH (MA)
Entity Type:Individual
Prefix:
First Name:MARSH
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 907
Mailing Address - Street 2:
Mailing Address - City:CLOVERDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95425-5427
Mailing Address - Country:US
Mailing Address - Phone:707-565-7676
Mailing Address - Fax:
Practice Address - Street 1:2655 BENNETT VALLEY ROAD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404
Practice Address - Country:US
Practice Address - Phone:707-565-7676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2020-10-21
Deactivation Date:2011-06-28
Deactivation Code:
Reactivation Date:2020-10-20
Provider Licenses
StateLicense IDTaxonomies
CA29870106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist