Provider Demographics
NPI:1639624828
Name:ROSE, SVETLANA NIKOLAYEVNA
Entity Type:Individual
Prefix:
First Name:SVETLANA
Middle Name:NIKOLAYEVNA
Last Name:ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SVETLANA
Other - Middle Name:NIKOLAYEVNA
Other - Last Name:ANOKHINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1296 FERN HILL CT
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32312-3944
Mailing Address - Country:US
Mailing Address - Phone:850-284-4093
Mailing Address - Fax:
Practice Address - Street 1:1713 MAHAN DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-1218
Practice Address - Country:US
Practice Address - Phone:850-681-6001
Practice Address - Fax:850-681-6003
Is Sole Proprietor?:No
Enumeration Date:2016-08-17
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH14641101YM0800X
FLMH17051101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health