Provider Demographics
NPI:1457361875
Name:LA ROSE, DANA JO (LICSW, LADC)
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:JO
Last Name:LA ROSE
Suffix:
Gender:F
Credentials:LICSW, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 216
Mailing Address - Street 2:
Mailing Address - City:DORSET
Mailing Address - State:VT
Mailing Address - Zip Code:05251-0216
Mailing Address - Country:US
Mailing Address - Phone:802-867-2437
Mailing Address - Fax:
Practice Address - Street 1:29 MADISON ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-5004
Practice Address - Country:US
Practice Address - Phone:802-345-9495
Practice Address - Fax:802-775-9698
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT000141101YA0400X
VT103454101YA0400X
VT101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0VN1124Medicaid
VT613355OtherMVP HEALTH PLAN
VT19888OtherBLUECROSS & BLUE SHIELD
VT0VN1124Medicaid