Provider Demographics
NPI:1437636412
Name:ROSEN, SUSAN CLARE (OT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:CLARE
Last Name:ROSEN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 JUDSON PL
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-7323
Mailing Address - Country:US
Mailing Address - Phone:410-212-5057
Mailing Address - Fax:
Practice Address - Street 1:1410 FOREST DR STE 29
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21403-1446
Practice Address - Country:US
Practice Address - Phone:410-280-8774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01762225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD01762OtherLICENSE NUMBER