Provider Demographics
NPI:1962815811
Name:ROSE, ROGER (PLPC)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:
Last Name:ROSE
Suffix:
Gender:M
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8804 NW 85TH ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64153-1676
Mailing Address - Country:US
Mailing Address - Phone:816-741-6280
Mailing Address - Fax:
Practice Address - Street 1:207 BROADMOOR DR
Practice Address - Street 2:
Practice Address - City:RAYMORE
Practice Address - State:MO
Practice Address - Zip Code:64083-9298
Practice Address - Country:US
Practice Address - Phone:816-377-0108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-09
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013044749101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health