Provider Demographics
NPI:1639757941
Name:ROSE, TAKARA CHEYENNE
Entity Type:Individual
Prefix:
First Name:TAKARA
Middle Name:CHEYENNE
Last Name:ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:ENNIS
Mailing Address - State:TX
Mailing Address - Zip Code:75119
Mailing Address - Country:US
Mailing Address - Phone:469-585-4802
Mailing Address - Fax:
Practice Address - Street 1:1012 COMMERCIAL BLVD N
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76001-7119
Practice Address - Country:US
Practice Address - Phone:817-557-8040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-30
Last Update Date:2021-06-15
Deactivation Date:2021-05-10
Deactivation Code:
Reactivation Date:2021-06-09
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician