Provider Demographics
NPI:1720785728
Name:ROSE, EVON MARIE (DO, OTD)
Entity Type:Individual
Prefix:
First Name:EVON
Middle Name:MARIE
Last Name:ROSE
Suffix:
Gender:F
Credentials:DO, OTD
Other - Prefix:
Other - First Name:EVON
Other - Middle Name:MARIE
Other - Last Name:MIKULECKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTD
Mailing Address - Street 1:6443 LOST ARBOR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-4925
Mailing Address - Country:US
Mailing Address - Phone:850-543-0184
Mailing Address - Fax:
Practice Address - Street 1:7615 KENNEDY HL
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78235-4437
Practice Address - Country:US
Practice Address - Phone:210-283-6438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-09
Last Update Date:2024-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX121057225X00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist