Provider Demographics
NPI:1619582095
Name:ROSE, NAOMI (LICSW)
Entity type:Individual
Prefix:
First Name:NAOMI
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5871 CEDAR LAKE RD S STE 202
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1479
Mailing Address - Country:US
Mailing Address - Phone:952-652-3439
Mailing Address - Fax:952-674-6270
Practice Address - Street 1:5871 CEDAR LAKE RD S STE 202
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1479
Practice Address - Country:US
Practice Address - Phone:952-652-3439
Practice Address - Fax:952-674-6270
Is Sole Proprietor?:No
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN249511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical