Healthcare Provider Details

I. General information

NPI: 1538104708
Provider Name (Legal Business Name): ROSE LAFFERTY L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 03/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 W MAIN CROSS ST
TAYLORVILLE IL
62568-2155
US

IV. Provider business mailing address

403 W MAIN CROSS ST
TAYLORVILLE IL
62568-2155
US

V. Phone/Fax

Practice location:
  • Phone: 217-824-6431
  • Fax: 217-824-6431
Mailing address:
  • Phone: 217-824-6431
  • Fax: 217-824-6431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149-002712
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: