Provider Demographics
NPI:1801685706
Name:ROSE, LYDIA (MPS, LADC)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:ROSE
Suffix:
Gender:
Credentials:MPS, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4404 NICOLLET AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-2642
Mailing Address - Country:US
Mailing Address - Phone:612-208-9629
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 73
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MN
Practice Address - Zip Code:55373-0073
Practice Address - Country:US
Practice Address - Phone:612-208-9629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-06
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X
MN306922101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health