Provider Demographics
NPI:1962521047
Name:ROSE, CHARLENE (MFT)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 14TH ST STE 110
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-2661
Mailing Address - Country:US
Mailing Address - Phone:209-480-8496
Mailing Address - Fax:209-343-3985
Practice Address - Street 1:426 14TH ST STE 110
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-2661
Practice Address - Country:US
Practice Address - Phone:209-480-8496
Practice Address - Fax:209-343-3985
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45144106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist