Healthcare Provider Details

I. General information

NPI: 1801730825
Provider Name (Legal Business Name): AMANDA MARIE ROSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2026
Last Update Date: 04/18/2026
Certification Date: 04/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 BROADWAY BLVD SE
ALBUQUERQUE NM
87102-3425
US

IV. Provider business mailing address

4808 DANUBE DR NE
ALBUQUERQUE NM
87111-2721
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-6988
  • Fax:
Mailing address:
  • Phone: 505-242-6988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2026-0316
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: