MEDICARE: DEREK ROSE MS, LPC

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	101YM0800X	Mental Health Counselor	0701012026	VA

General Provider Information

NPI Number	:	1851094353
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEREK ROSE MS, LPC

Provider Business Mailing Address
First Line	:	15 CLEVELAND AVE STE 11
Second Line	:
City	:	MARTINSVILLE
State	:	VA
Zip	:	24112-2926
Country	:	US
Telephone Number	:	276-634-8304
Fax Number	:

Provider Business Practice Location Address
First Line	:	15 CLEVELAND AVE STE 11
Second Line	:
City	:	MARTINSVILLE
State	:	VA
Zip	:	24112-2926
Country	:	US
Telephone Number	:	276-634-8304
Fax Number	:	276-258-6476

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

Provider Enumeration Date	:	03/23/2023
Last Update Date	:	03/23/2023

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