Provider Demographics
NPI:1497340335
Name:ROSE, VICTORIA RITA (MSOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:RITA
Last Name:ROSE
Suffix:
Gender:F
Credentials:MSOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 FOUNTAIN POINTE LN UNIT 302
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-7416
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 FOUNTAIN POINTE LN UNIT 302
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-7416
Practice Address - Country:US
Practice Address - Phone:845-421-1803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-03
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCOT.6081225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist