Provider Demographics
NPI:1710134838
Name:ROMAN GONZALEZ, ROSA M (OT)
Entity Type:Individual
Prefix:MRS
First Name:ROSA
Middle Name:M
Last Name:ROMAN GONZALEZ
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:ROSA
Other - Middle Name:M
Other - Last Name:SERRANO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OT
Mailing Address - Street 1:6164 WILLOUGHBY CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33463-9308
Mailing Address - Country:US
Mailing Address - Phone:732-896-8373
Mailing Address - Fax:
Practice Address - Street 1:6164 WILLOUGHBY CIR
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33463-9308
Practice Address - Country:US
Practice Address - Phone:732-896-8373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 13282225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics