Provider Demographics
NPI:1134552466
Name:ROSE, FARA WILEEN (OTR/L)
Entity type:Individual
Prefix:MISS
First Name:FARA
Middle Name:WILEEN
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 1:455 W 44TH ST
Mailing Address - Street 2:APT.27
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-4424
Mailing Address - Country:US
Mailing Address - Phone:917-623-1118
Mailing Address - Fax:
Practice Address - Street 1:455 W 44TH ST
Practice Address - Street 2:APT.27
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-4424
Practice Address - Country:US
Practice Address - Phone:917-623-1118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-09
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017258-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist