Provider Demographics
NPI:1508141888
Name:ROSE, COLLEEN (MOTR)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:MOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 SANDRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:HUBERT
Mailing Address - State:NC
Mailing Address - Zip Code:28539-4362
Mailing Address - Country:US
Mailing Address - Phone:732-599-4813
Mailing Address - Fax:910-792-6706
Practice Address - Street 1:219 RACINE DR
Practice Address - Street 2:SUITE 1-A
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-8827
Practice Address - Country:US
Practice Address - Phone:910-792-6706
Practice Address - Fax:910-792-6706
Is Sole Proprietor?:No
Enumeration Date:2011-10-18
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8556225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist