Provider Demographics
NPI:1457764979
Name:ROSE, DIANE PERCEVAULT (LPC)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:PERCEVAULT
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 1:14 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08553-1026
Mailing Address - Country:US
Mailing Address - Phone:609-924-6138
Mailing Address - Fax:
Practice Address - Street 1:750 BRUNSWICK AVE
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08638-4143
Practice Address - Country:US
Practice Address - Phone:609-394-6086
Practice Address - Fax:609-396-0952
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00185700101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional