Provider Demographics
NPI:1669655494
Name:ROSE, JON MITCHEL (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:MITCHEL
Last Name:ROSE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 BONIFACE DR
Mailing Address - Street 2:P.O. BOX 912
Mailing Address - City:PINE BUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12566-7011
Mailing Address - Country:US
Mailing Address - Phone:845-744-6974
Mailing Address - Fax:845-744-6406
Practice Address - Street 1:89 BONIFACE DR
Practice Address - Street 2:
Practice Address - City:PINE BUSH
Practice Address - State:NY
Practice Address - Zip Code:12566-7011
Practice Address - Country:US
Practice Address - Phone:845-744-6974
Practice Address - Fax:845-744-6406
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-16
Last Update Date:2007-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRO44407-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical