Provider Demographics
NPI:1942745864
Name:ROSE, TONY I (LSW)
Entity type:Individual
Prefix:MR
First Name:TONY
Middle Name:
Last Name:ROSE
Suffix:I
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 W SANDUSKY ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:43019-1251
Mailing Address - Country:US
Mailing Address - Phone:512-800-1234
Mailing Address - Fax:
Practice Address - Street 1:400 E STATE ST STE D
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-1870
Practice Address - Country:US
Practice Address - Phone:740-249-4514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-01
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1610519-TRNE101YM0800X
OHS.1901009-TRNE104100000X
390200000X
OHS.2309921104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program