Provider Demographics
NPI:1003289620
Name:ROSE, BRIDGET (PTA)
Entity Type:Individual
Prefix:MRS
First Name:BRIDGET
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:BRIDGET
Other - Middle Name:SUZANNE
Other - Last Name:SHEPHERD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:600 W OWENS ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-1246
Mailing Address - Country:US
Mailing Address - Phone:618-967-5186
Mailing Address - Fax:
Practice Address - Street 1:600 W OWENS ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1246
Practice Address - Country:US
Practice Address - Phone:618-967-5186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-04
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160005138225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant