Provider Demographics
NPI:1457539702
Name:ROSE, CHRYSTA LOUISE (MA)
Entity Type:Individual
Prefix:
First Name:CHRYSTA
Middle Name:LOUISE
Last Name:ROSE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:479 RUSSELL ST STE 102
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-7331
Mailing Address - Country:US
Mailing Address - Phone:541-708-1403
Mailing Address - Fax:
Practice Address - Street 1:479 RUSSELL ST STE 102
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-7331
Practice Address - Country:US
Practice Address - Phone:541-708-1403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-07
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60152242101YM0800X
ORT0825106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health