Basic Information
Provider Information | |||||||||
NPI: | 1710163365 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROSE | ||||||||
FirstName: | LISA | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3001 WARRIOR LN | ||||||||
Address2: |   | ||||||||
City: | POPLAR BLUFF | ||||||||
State: | MO | ||||||||
PostalCode: | 639018685 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5736861200 | ||||||||
FaxNumber: | 5736861029 | ||||||||
Practice Location | |||||||||
Address1: | 925 HIGHWAY V V | ||||||||
Address2: |   | ||||||||
City: | KENNETT | ||||||||
State: | MO | ||||||||
PostalCode: | 638577707 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5738885925 | ||||||||
FaxNumber: | 5738889365 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/14/2008 | ||||||||
LastUpdateDate: | 08/06/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 2006038844 | MO | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | 1710163365 | 05 | MO |   | MEDICAID | 17101063365 | 05 | MO |   | MEDICAID |