Provider Demographics
NPI:1396142006
Name:ROSENBECK-ROSE, KIMBERLY SUE (LPCC-S)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUE
Last Name:ROSENBECK-ROSE
Suffix:
Gender:F
Credentials:LPCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3922 MENCHHOFER RD
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:OH
Mailing Address - Zip Code:45828-8739
Mailing Address - Country:US
Mailing Address - Phone:567-644-8186
Mailing Address - Fax:
Practice Address - Street 1:330 PORTLAND ST STE A
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:OH
Practice Address - Zip Code:45822-2038
Practice Address - Country:US
Practice Address - Phone:567-644-8186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-24
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.1800539-SUPV101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0263892Medicaid