Provider Demographics
NPI:1922428564
Name:ROSE, ERIC (MA)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:ROSE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:ERIC
Other - Middle Name:
Other - Last Name:NORMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:905 SE 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-2569
Mailing Address - Country:US
Mailing Address - Phone:503-622-8964
Mailing Address - Fax:503-715-5469
Practice Address - Street 1:905 SE 14TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2569
Practice Address - Country:US
Practice Address - Phone:503-622-8964
Practice Address - Fax:503-715-5469
Is Sole Proprietor?:No
Enumeration Date:2014-04-22
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health