Provider Demographics
NPI:1851094353
Name:ROSE, DEREK (MS, LPC)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:ROSE
Suffix:
Gender:M
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 CLEVELAND AVE STE 11
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-2926
Mailing Address - Country:US
Mailing Address - Phone:276-634-8304
Mailing Address - Fax:
Practice Address - Street 1:15 CLEVELAND AVE STE 11
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-2926
Practice Address - Country:US
Practice Address - Phone:276-634-8304
Practice Address - Fax:276-258-6476
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-23
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701012026101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health