Provider Demographics
NPI:1407487549
Name:NIEBUHR, ROSIE M
Entity Type:Individual
Prefix:
First Name:ROSIE
Middle Name:M
Last Name:NIEBUHR
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 1:2926 MEADOW BROOK TRL
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-5101
Mailing Address - Country:US
Mailing Address - Phone:903-316-2268
Mailing Address - Fax:
Practice Address - Street 1:520 DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8307
Practice Address - Country:US
Practice Address - Phone:903-316-2268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX170551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty