Provider Demographics
NPI:1467807016
Name:ROSE, CONNOR LAWRENCE (PSYD)
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:LAWRENCE
Last Name:ROSE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2551 CHARNEY RD
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-4402
Mailing Address - Country:US
Mailing Address - Phone:503-558-5887
Mailing Address - Fax:
Practice Address - Street 1:2551 CHARNEY RD
Practice Address - Street 2:
Practice Address - City:UNIVERSITY HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44118-4402
Practice Address - Country:US
Practice Address - Phone:503-558-5887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-02
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810007422103T00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist