Provider Demographics
NPI:1649609694
Name:ROSE, LETICIA DELON (MSOT)
Entity type:Individual
Prefix:MS
First Name:LETICIA
Middle Name:DELON
Last Name:ROSE
Suffix:
Gender:F
Credentials:MSOT
Other - Prefix:
Other - First Name:LETICIA
Other - Middle Name:DELEON
Other - Last Name:HERNANDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4004 CASHEW DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-9540
Mailing Address - Country:US
Mailing Address - Phone:919-455-8692
Mailing Address - Fax:
Practice Address - Street 1:5301 CREEDMOOR RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-3822
Practice Address - Country:US
Practice Address - Phone:919-651-3803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-09
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7531225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist