Healthcare Provider Details

I. General information

NPI: 1558127530
Provider Name (Legal Business Name): CALLIE ROSE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2024
Last Update Date: 02/26/2024
Certification Date: 02/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1169 EASTERN PKWY
LOUISVILLE KY
40217-1417
US

IV. Provider business mailing address

1805 S PRESTON ST
LOUISVILLE KY
40217-1042
US

V. Phone/Fax

Practice location:
  • Phone: 855-591-0092
  • Fax:
Mailing address:
  • Phone: 502-649-7072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number258769
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: