MEDICARE: CONNOR LAWRENCE ROSE PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	0810007422	VA

General Provider Information

NPI Number	:	1467807016
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CONNOR LAWRENCE ROSE PSYD

Provider Business Mailing Address
First Line	:	2551 CHARNEY RD
Second Line	:
City	:	UNIVERSITY HEIGHTS
State	:	OH
Zip	:	44118-4402
Country	:	US
Telephone Number	:	503-558-5887
Fax Number	:

Provider Business Practice Location Address
First Line	:	2551 CHARNEY RD
Second Line	:
City	:	UNIVERSITY HEIGHTS
State	:	OH
Zip	:	44118-4402
Country	:	US
Telephone Number	:	503-558-5887
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2016
Last Update Date	:	10/16/2024

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