Provider Demographics
NPI:1134684731
Name:ROSE, EZRA
Entity type:Individual
Prefix:
First Name:EZRA
Middle Name:
Last Name:ROSE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:BREEANNA
Other - Middle Name:ROSE
Other - Last Name:SPEICHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:580 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89503-4407
Mailing Address - Country:US
Mailing Address - Phone:775-786-4673
Mailing Address - Fax:
Practice Address - Street 1:580 W 5TH ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-4407
Practice Address - Country:US
Practice Address - Phone:775-786-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-07
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NVCHW2-5094172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician