=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750701751
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BARBARA ROSE MA, CADC III, MAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2014
-----------------------------------------------------
Last Update Date | 05/06/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12555 SW 1ST ST
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97005-0546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-407-1703
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15675 SW BEVERLY BEACH CT
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97007-5025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-407-1703
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 10-R-22
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------