Provider Demographics
NPI:1972155240
Name:ROSE, HALEY (OTR)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7595 S MISSISSIPPI RIVER RD
Mailing Address - Street 2:
Mailing Address - City:GOLDEN EAGLE
Mailing Address - State:IL
Mailing Address - Zip Code:62036-2134
Mailing Address - Country:US
Mailing Address - Phone:618-520-7122
Mailing Address - Fax:
Practice Address - Street 1:11960 WESTLINE INDUSTRIAL DR STE 201
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-3209
Practice Address - Country:US
Practice Address - Phone:314-819-0048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics