Provider Demographics
NPI:1457431660
Name:HOLLOW HORN BEAR, ROSE E (MA, MFT INTERN)
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:E
Last Name:HOLLOW HORN BEAR
Suffix:
Gender:F
Credentials:MA, MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1579
Mailing Address - Street 2:
Mailing Address - City:SHINGLE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95682-1579
Mailing Address - Country:US
Mailing Address - Phone:530-672-8059
Mailing Address - Fax:530-672-8057
Practice Address - Street 1:4140 MOTHER LODE DR
Practice Address - Street 2:104
Practice Address - City:SHINGLE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:95682-8038
Practice Address - Country:US
Practice Address - Phone:530-672-8059
Practice Address - Fax:530-672-8057
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64494106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist