Provider Demographics
NPI:1770098139
Name:ROSE, ANDREW JUSTIN BAKER (CSAC, QMHP-A, LAC)
Entity type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:JUSTIN BAKER
Last Name:ROSE
Suffix:
Gender:M
Credentials:CSAC, QMHP-A, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 S MAIN CROSS ST
Mailing Address - Street 2:
Mailing Address - City:LOUISA
Mailing Address - State:KY
Mailing Address - Zip Code:41230-1065
Mailing Address - Country:US
Mailing Address - Phone:606-638-0938
Mailing Address - Fax:859-813-5394
Practice Address - Street 1:125 S MAIN CROSS ST
Practice Address - Street 2:
Practice Address - City:LOUISA
Practice Address - State:KY
Practice Address - Zip Code:41230-1065
Practice Address - Country:US
Practice Address - Phone:606-638-0938
Practice Address - Fax:859-813-5394
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-07
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY175461101YA0400X
IN86000431A101YA0400X
VA0710103608101YA0400X
VA0732008841101YM0800X
171M00000X
KY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health