Healthcare Provider Details

I. General information

NPI: 1801287248
Provider Name (Legal Business Name): DOUG ROSE LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ROBERT DOUG ROSE LPC

II. Dates (important events)

Enumeration Date: 02/06/2015
Last Update Date: 02/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2545 HIGHWAY 4
JONESBORO LA
71251-6909
US

IV. Provider business mailing address

PO BOX 9
QUITMAN LA
71268-0009
US

V. Phone/Fax

Practice location:
  • Phone: 318-439-1399
  • Fax: 855-334-8166
Mailing address:
  • Phone: 318-439-1399
  • Fax: 855-334-8166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2509
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: