Provider Demographics
NPI:1912049719
Name:ROSE, ROSALIND SERENA (LCPC, LAC,)
Entity Type:Individual
Prefix:MS
First Name:ROSALIND
Middle Name:SERENA
Last Name:ROSE
Suffix:
Gender:F
Credentials:LCPC, LAC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 PHEASANT BROOK CIRCLE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:LAUREL
Mailing Address - State:MT
Mailing Address - Zip Code:59044-9314
Mailing Address - Country:US
Mailing Address - Phone:406-696-3111
Mailing Address - Fax:
Practice Address - Street 1:1615 PHEASANT BROOK CIRCLE
Practice Address - Street 2:SUITE 2
Practice Address - City:LAUREL
Practice Address - State:MT
Practice Address - Zip Code:59044-9314
Practice Address - Country:US
Practice Address - Phone:406-696-3111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1000101YA0400X, 101YM0800X
UT332925-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT740150OtherBLUE CROSS BLUE SHIELD PR
MT0254830Medicaid