Provider Demographics
NPI:1952649345
Name:ROSE, ALICIA
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8812 SANDY CREST CT
Mailing Address - Street 2:
Mailing Address - City:WHITE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48386-2449
Mailing Address - Country:US
Mailing Address - Phone:313-742-3420
Mailing Address - Fax:
Practice Address - Street 1:8812 SANDY CREST CT
Practice Address - Street 2:
Practice Address - City:WHITE LAKE
Practice Address - State:MI
Practice Address - Zip Code:48386-2449
Practice Address - Country:US
Practice Address - Phone:313-742-3420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-21
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI128698-1211041C0700X
MI69010990351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801099035OtherLICENSED MASTER SOCIAL WORKER
WI128698-121OtherADVANCED PRACTICE SOCIAL WORKER