Provider Demographics
NPI:1598067860
Name:ROE, PHILLIP (COTA)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:ROE
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:569 MARDELL LN
Mailing Address - Street 2:
Mailing Address - City:HOWE
Mailing Address - State:TX
Mailing Address - Zip Code:75459-4452
Mailing Address - Country:US
Mailing Address - Phone:903-532-3945
Mailing Address - Fax:
Practice Address - Street 1:569 MARDELL LN
Practice Address - Street 2:
Practice Address - City:HOWE
Practice Address - State:TX
Practice Address - Zip Code:75459-4452
Practice Address - Country:US
Practice Address - Phone:903-532-3945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-18
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX206750224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant