Provider Demographics
NPI:1740359843
Name:ROSE, INGRID (PHD LPC)
Entity type:Individual
Prefix:DR
First Name:INGRID
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:PHD LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:922 NW 11TH AVE
Mailing Address - Street 2:APT 403
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2776
Mailing Address - Country:US
Mailing Address - Phone:503-248-1608
Mailing Address - Fax:503-248-1608
Practice Address - Street 1:922 NW 11TH AVE
Practice Address - Street 2:APT 403
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2776
Practice Address - Country:US
Practice Address - Phone:503-248-1608
Practice Address - Fax:503-248-1608
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORC3057101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health