Provider Demographics
NPI:1689128001
Name:ROSE, WAKANDA (MA)
Entity Type:Individual
Prefix:
First Name:WAKANDA
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 1:254 BREY RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-5556
Mailing Address - Country:US
Mailing Address - Phone:707-583-9304
Mailing Address - Fax:
Practice Address - Street 1:254 BREY RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95409-5556
Practice Address - Country:US
Practice Address - Phone:707-583-9304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-15
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health