Provider Demographics
NPI:1114517174
Name:PIEDALUE, ROSELIS EDITH
Entity Type:Individual
Prefix:
First Name:ROSELIS
Middle Name:EDITH
Last Name:PIEDALUE
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 1:28710 PEARL BRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-3876
Mailing Address - Country:US
Mailing Address - Phone:720-499-7880
Mailing Address - Fax:
Practice Address - Street 1:28710 PEARL BRIDGE LN
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-3876
Practice Address - Country:US
Practice Address - Phone:720-499-7880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-24
Last Update Date:2021-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT134317225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO82-1438740Medicaid