Provider Demographics
NPI:1639612062
Name:ROSE, LARRI (MS, NCC, LPC)
Entity Type:Individual
Prefix:
First Name:LARRI
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:MS, NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6468 PAULA CT
Mailing Address - Street 2:
Mailing Address - City:REX
Mailing Address - State:GA
Mailing Address - Zip Code:30273-1636
Mailing Address - Country:US
Mailing Address - Phone:770-639-8434
Mailing Address - Fax:
Practice Address - Street 1:6468 PAULA CT
Practice Address - Street 2:
Practice Address - City:REX
Practice Address - State:GA
Practice Address - Zip Code:30273-1636
Practice Address - Country:US
Practice Address - Phone:770-639-8434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-03
Last Update Date:2016-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008419101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional