Provider Demographics
NPI:1366566036
Name:ROSE, VICKI J (BS,CADC)
Entity type:Individual
Prefix:MS
First Name:VICKI
Middle Name:J
Last Name:ROSE
Suffix:
Gender:F
Credentials:BS,CADC
Other - Prefix:MS
Other - First Name:VICKI
Other - Middle Name:J
Other - Last Name:DRAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2323 WINDISH DR
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-9780
Mailing Address - Country:US
Mailing Address - Phone:309-344-2323
Mailing Address - Fax:309-344-4368
Practice Address - Street 1:2323 WINDISH DR
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-9780
Practice Address - Country:US
Practice Address - Phone:309-344-4200
Practice Address - Fax:309-344-4281
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370984175OtherFEIN ORGANIZATION