Provider Demographics
NPI:1003261850
Name:ROSE, GRETCHAN
Entity Type:Individual
Prefix:
First Name:GRETCHAN
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 CAYUGA AVE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-4303
Mailing Address - Country:US
Mailing Address - Phone:814-946-0471
Mailing Address - Fax:814-944-4792
Practice Address - Street 1:700 CAYUGA AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-4303
Practice Address - Country:US
Practice Address - Phone:814-946-0471
Practice Address - Fax:814-944-4792
Is Sole Proprietor?:No
Enumeration Date:2016-04-29
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC007451L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA395241Medicare UPIN