Provider Demographics
NPI:1356872477
Name:ROSE, VERNON JR (CADC II)
Entity type:Individual
Prefix:MR
First Name:VERNON
Middle Name:
Last Name:ROSE
Suffix:JR
Gender:M
Credentials:CADC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4211 W 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-5435
Mailing Address - Country:US
Mailing Address - Phone:541-485-1577
Mailing Address - Fax:541-242-2853
Practice Address - Street 1:4211 W 11TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-5435
Practice Address - Country:US
Practice Address - Phone:541-485-1577
Practice Address - Fax:541-242-2853
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR07-09-64101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR07-09-64OtherCERTIFIED ALCOHOL AND DRUG COUNSELOR LEVEL II
OR500730386Medicaid