Healthcare Provider Details

I. General information

NPI: 1104452630
Provider Name (Legal Business Name): KYLE R ROSE PHD, LPC, NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2020
Last Update Date: 01/22/2026
Certification Date: 01/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 BEVERLY ROAD, SUITE 200
MCLEAN VA
22101
US

IV. Provider business mailing address

703 N MARKET ST
SELINSGROVE PA
17870-2007
US

V. Phone/Fax

Practice location:
  • Phone: 703-831-8300
  • Fax:
Mailing address:
  • Phone: 717-921-7004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701011286
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPC018564
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701011286
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC018564
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: