MEDICARE: MR. MARK L ROSE CDP, BA, ICRC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	CP 60073428	WA

General Provider Information

NPI Number	:	1326494592
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK L ROSE CDP, BA, ICRC

Provider Business Mailing Address
First Line	:	4600 36TH AVE SW
Second Line	:	#412
City	:	SEATTLE
State	:	WA
Zip	:	98126-2794
Country	:	US
Telephone Number	:	206-419-5664
Fax Number	:

Provider Business Practice Location Address
First Line	:	4600 36TH AVE SW
Second Line	:	#412
City	:	SEATTLE
State	:	WA
Zip	:	98126-2794
Country	:	US
Telephone Number	:	206-419-5664
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/06/2016
Last Update Date	:	05/06/2016

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