Provider Demographics
NPI:1336406198
Name:ROSE, SHANNON (MSW CSWA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:MSW CSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 E MAIN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7136
Mailing Address - Country:US
Mailing Address - Phone:541-842-7705
Mailing Address - Fax:541-842-7640
Practice Address - Street 1:8385 DIVISION RD
Practice Address - Street 2:
Practice Address - City:WHITE CITY
Practice Address - State:OR
Practice Address - Zip Code:97503-1176
Practice Address - Country:US
Practice Address - Phone:541-826-5853
Practice Address - Fax:541-826-5843
Is Sole Proprietor?:No
Enumeration Date:2012-04-18
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL64981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical