Provider Demographics
NPI:1831678168
Name:ROSE, KATHRYN ANNE (MSW-I)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ANNE
Last Name:ROSE
Suffix:
Gender:F
Credentials:MSW-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 E 4500 S STE 300
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-4502
Mailing Address - Country:US
Mailing Address - Phone:800-261-3500
Mailing Address - Fax:
Practice Address - Street 1:75 E FORT UNION BLVD STE 135
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-1531
Practice Address - Country:US
Practice Address - Phone:801-603-2547
Practice Address - Fax:801-649-0964
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1831678168Medicaid