Provider Demographics
NPI:1407929359
Name:ROSE, SHERRICE BROUSSARD (PT DPT)
Entity Type:Individual
Prefix:
First Name:SHERRICE
Middle Name:BROUSSARD
Last Name:ROSE
Suffix:
Gender:F
Credentials:PT DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2307 S DALE MABRY HWY STE F
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-6322
Mailing Address - Country:US
Mailing Address - Phone:813-374-9508
Mailing Address - Fax:
Practice Address - Street 1:2307 S DALE MABRY HWY STE F
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-6322
Practice Address - Country:US
Practice Address - Phone:813-374-9508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT266982251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65BBDFCMedicare PIN