Provider Demographics
NPI:1871012963
Name:ROSE, MARY LEE (OTR/L)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LEE
Last Name:ROSE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 N COPPELL RD
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-2044
Mailing Address - Country:US
Mailing Address - Phone:443-416-1119
Mailing Address - Fax:
Practice Address - Street 1:915 W EXCHANGE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-7018
Practice Address - Country:US
Practice Address - Phone:214-547-1571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-11
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118551225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist