Provider Demographics
NPI:1891811519
Name:ROSE, STACEY ANN (MSW, LICSW)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:ANN
Last Name:ROSE
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1624 E GORDON AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99207-4650
Mailing Address - Country:US
Mailing Address - Phone:509-343-5042
Mailing Address - Fax:
Practice Address - Street 1:210 W SPRAGUE AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-3627
Practice Address - Country:US
Practice Address - Phone:509-343-5042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000071121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical