Provider Demographics
NPI:1366161366
Name:WHITE, MARY ROSE (LPC)
Entity type:Individual
Prefix:
First Name:MARY ROSE
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:ROSE
Other - Middle Name:
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:410 S ORCHARD ST STE 160
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-1295
Mailing Address - Country:US
Mailing Address - Phone:208-617-4228
Mailing Address - Fax:
Practice Address - Street 1:410 S ORCHARD ST STE 160
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1295
Practice Address - Country:US
Practice Address - Phone:208-617-4228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-8273101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional