Basic Information
| Provider Information | |||||||||
| NPI: | 1689076143 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSE CRENSHAW | ||||||||
| FirstName: | ALYSSA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROSE | ||||||||
| OtherFirstName: | ALYSSA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3415 SE PWELL BLVD. | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032349591 | ||||||||
| FaxNumber: | 5036976932 | ||||||||
| Practice Location | |||||||||
| Address1: | 1715 SE 32ND PLACE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032349591 | ||||||||
| FaxNumber: | 5036976932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2014 | ||||||||
| LastUpdateDate: | 11/08/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | C3877 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.