Provider Demographics
NPI:1689706889
Name:MITCHELL, ROSE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ROSE
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1712 GROVETON WAY
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-1904
Mailing Address - Country:US
Mailing Address - Phone:209-558-2848
Mailing Address - Fax:209-558-1075
Practice Address - Street 1:251 E HACKETT RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95358-9415
Practice Address - Country:US
Practice Address - Phone:209-558-2848
Practice Address - Fax:209-558-1075
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS18764101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional