Provider Demographics
NPI:1689626293
Name:ROSE, MICHAEL RICHARD (LCSW, PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RICHARD
Last Name:ROSE
Suffix:
Gender:M
Credentials:LCSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6604 W TONTO DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-7026
Mailing Address - Country:US
Mailing Address - Phone:602-316-3529
Mailing Address - Fax:623-444-7643
Practice Address - Street 1:4915 W BELL RD
Practice Address - Street 2:SUITE 202
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-3425
Practice Address - Country:US
Practice Address - Phone:602-316-3529
Practice Address - Fax:623-444-7643
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-3693101Y00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor