Provider Demographics
NPI:1720685142
Name:ROSE, CHERYL (MHC-LP, CASAC-T)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:MHC-LP, CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102-35 64TH RD
Mailing Address - Street 2:GF
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375
Mailing Address - Country:US
Mailing Address - Phone:929-900-5624
Mailing Address - Fax:646-844-5961
Practice Address - Street 1:102-35 64TH RD
Practice Address - Street 2:GF
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-1545
Practice Address - Country:US
Practice Address - Phone:929-900-5624
Practice Address - Fax:646-844-5961
Is Sole Proprietor?:No
Enumeration Date:2020-10-08
Last Update Date:2022-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
NYP105777101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)