Provider Demographics
NPI:1457067191
Name:ROSE, LISA S (LPC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:S
Last Name:ROSE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10710 MIDLOTHIAN TPKE STE 127
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23235-4776
Mailing Address - Country:US
Mailing Address - Phone:804-207-6737
Mailing Address - Fax:
Practice Address - Street 1:10710 MIDLOTHIAN TPKE STE 127
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-4776
Practice Address - Country:US
Practice Address - Phone:673-780-4207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-26
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701012117101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30017644370001Medicaid