Provider Demographics
NPI:1447586409
Name:EAGLE, ROSE (PHD)
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:EAGLE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7707 SW CAPITOL HWY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-2458
Mailing Address - Country:US
Mailing Address - Phone:503-452-8002
Mailing Address - Fax:503-452-0084
Practice Address - Street 1:7707 SW CAPITOL HWY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-2458
Practice Address - Country:US
Practice Address - Phone:503-452-8002
Practice Address - Fax:503-452-0084
Is Sole Proprietor?:No
Enumeration Date:2009-10-27
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1951103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical