Healthcare Provider Details

I. General information

NPI: 1447833165
Provider Name (Legal Business Name): HOLLY KATHERYNE ROSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2021
Last Update Date: 04/30/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14532 STATE ROUTE 23
WAVERLY OH
45690
US

IV. Provider business mailing address

1113 KENT ST APT 8G
PORTSMOUTH OH
45662-2564
US

V. Phone/Fax

Practice location:
  • Phone: 740-947-2364
  • Fax:
Mailing address:
  • Phone: 740-949-6727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: