Basic Information
| Provider Information | |||||||||
| NPI: | 1326768656 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSE | ||||||||
| FirstName: | SERRA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 233 SGT ED HOLCOMB BLVD S | ||||||||
| Address2: | |||||||||
| City: | CONROE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773041990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9365216100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 233 SGT ED HOLCOMB BLVD S | ||||||||
| Address2: | |||||||||
| City: | CONROE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773041990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9365216100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2022 | ||||||||
| LastUpdateDate: | 09/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 82055 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.