Healthcare Provider Details

I. General information

NPI: 1285409391
Provider Name (Legal Business Name): ROSE PSYCHOTHERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2023
Last Update Date: 01/02/2024
Certification Date: 01/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16204 HIGHWAY 7
MINNETONKA MN
55345-3405
US

IV. Provider business mailing address

7771 157TH ST W
SAINT PAUL MN
55124-6362
US

V. Phone/Fax

Practice location:
  • Phone: 612-293-8564
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CALLIE ROSE
Title or Position: OWNER/PROVIDER
Credential:
Phone: 612-293-8564