MEDICARE: DR. SARA R ROSE PH.D., LPC

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	101YP2500X	Professional Counselor	755	NC

General Provider Information

NPI Number	:	1619900511
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SARA R ROSE PH.D., LPC

Provider Business Mailing Address
First Line	:	3426 GRESHAM PL
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-3966
Country	:	US
Telephone Number	:	704-525-1213
Fax Number	:	704-525-1213

Provider Business Practice Location Address
First Line	:	1515 MOCKINGBIRD LN
Second Line	:	SUITE 411
City	:	CHARLOTTE
State	:	NC
Zip	:	28209-3236
Country	:	US
Telephone Number	:	704-525-1213
Fax Number	:	704-525-1213

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

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	07/08/2007

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