Provider Demographics
NPI:1750748422
Name:ROSE, LISA CHONG (LPCC)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:CHONG
Last Name:ROSE
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:CHONG JOU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2680 SNELLING AVE N STE 200
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-1879
Mailing Address - Country:US
Mailing Address - Phone:651-364-9381
Mailing Address - Fax:651-364-9382
Practice Address - Street 1:2680 SNELLING AVE N STE 200
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-1879
Practice Address - Country:US
Practice Address - Phone:651-364-9381
Practice Address - Fax:651-364-9382
Is Sole Proprietor?:No
Enumeration Date:2016-01-26
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2851101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health