Provider Demographics
NPI:1912316993
Name:ROSE, MARY (MA LPC CACII)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:MA LPC CACII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1301
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80502-1301
Mailing Address - Country:US
Mailing Address - Phone:720-340-2710
Mailing Address - Fax:
Practice Address - Street 1:709 3RD AVE
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-5926
Practice Address - Country:US
Practice Address - Phone:720-340-2710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-04
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11721101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)