Provider Demographics
NPI:1962150615
Name:SOUTHERN ROSE PSYCHOTHERAPY, LLC
Entity type:Organization
Organization Name:SOUTHERN ROSE PSYCHOTHERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:971-334-1940
Mailing Address - Street 1:2780 NEW HOLT RD STE D373
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-7441
Mailing Address - Country:US
Mailing Address - Phone:971-334-1940
Mailing Address - Fax:
Practice Address - Street 1:555 JEFFERSON ST STE 301
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-1088
Practice Address - Country:US
Practice Address - Phone:971-334-1940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-11
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1407393150Medicaid