Provider Demographics
NPI:1992533921
Name:ROSE, MARY CATHERINE (LAC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CATHERINE
Last Name:ROSE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:MOTE
Other - Middle Name:CATHERINE
Other - Last Name:MARY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:804 W FREEMAN AVE STE 9
Mailing Address - Street 2:
Mailing Address - City:BERRYVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72616-3141
Mailing Address - Country:US
Mailing Address - Phone:870-340-2636
Mailing Address - Fax:
Practice Address - Street 1:804 W FREEMAN AVE STE 9
Practice Address - Street 2:
Practice Address - City:BERRYVILLE
Practice Address - State:AR
Practice Address - Zip Code:72616-3141
Practice Address - Country:US
Practice Address - Phone:870-340-2636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2407006101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health