Provider Demographics
NPI:1104912872
Name:ROSE, DIANE K (CADC III, QMHP)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:K
Last Name:ROSE
Suffix:
Gender:F
Credentials:CADC III, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6440 CHESSINGTON LN
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:OR
Mailing Address - Zip Code:97027-1011
Mailing Address - Country:US
Mailing Address - Phone:503-353-6799
Mailing Address - Fax:
Practice Address - Street 1:131 NE 102ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-4167
Practice Address - Country:US
Practice Address - Phone:503-253-6754
Practice Address - Fax:503-253-8020
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health