Healthcare Provider Details

I. General information

NPI: 1265071484
Provider Name (Legal Business Name): HAROLD BERNARD ROSE III LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2020
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W MAUD ST STE 2
POPLAR BLUFF MO
63901-4726
US

IV. Provider business mailing address

1600 W MAUD ST STE 2
POPLAR BLUFF MO
63901-4726
US

V. Phone/Fax

Practice location:
  • Phone: 573-840-0615
  • Fax: 573-872-4797
Mailing address:
  • Phone: 573-840-0615
  • Fax: 573-872-4797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2018026062
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: