Provider Demographics
NPI:1104452630
Name:ROSE, KYLE R (LPC, NCC)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:R
Last Name:ROSE
Suffix:
Gender:M
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 BEVERLY ROAD, SUITE 200
Mailing Address - Street 2:
Mailing Address - City:MCLEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101
Mailing Address - Country:US
Mailing Address - Phone:703-831-8300
Mailing Address - Fax:
Practice Address - Street 1:1360 BEVERLY ROAD, SUITE 200
Practice Address - Street 2:
Practice Address - City:MCLEAN
Practice Address - State:VA
Practice Address - Zip Code:22101
Practice Address - Country:US
Practice Address - Phone:703-831-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-16
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701011286101YP2500X
101YM0800X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30017639620001Medicaid