Provider Demographics
NPI:1023386315
Name:ROSE, ABIGAIL ANN
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:ANN
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 1:697 LOUISIANA RD
Mailing Address - Street 2:
Mailing Address - City:DYESS AFB
Mailing Address - State:TX
Mailing Address - Zip Code:79607-1141
Mailing Address - Country:US
Mailing Address - Phone:256-968-3433
Mailing Address - Fax:
Practice Address - Street 1:697 LOUISIANA RD
Practice Address - Street 2:
Practice Address - City:DYESS AFB
Practice Address - State:TX
Practice Address - Zip Code:79607-1141
Practice Address - Country:US
Practice Address - Phone:256-968-3433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-01
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX55209172V00000X
NCC0086111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No172V00000XOther Service ProvidersCommunity Health Worker