Basic Information
| Provider Information | |||||||||
| NPI: | 1457725244 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSE | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | BRAD | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10 | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488540010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176769788 | ||||||||
| FaxNumber: | 5176763438 | ||||||||
| Practice Location | |||||||||
| Address1: | 4710 W SAGINAW HWY STE 1 | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489172654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176840577 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2015 | ||||||||
| LastUpdateDate: | 04/27/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401011149 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.