Provider Demographics
NPI:1801256417
Name:ROSE, AMANDA (COTA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 ACADEMY ST
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77803-4964
Mailing Address - Country:US
Mailing Address - Phone:979-574-6343
Mailing Address - Fax:
Practice Address - Street 1:1022 PRESIDENTIAL CORRIDOR
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:TX
Practice Address - Zip Code:77836-4611
Practice Address - Country:US
Practice Address - Phone:979-567-0920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-25
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX213556224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant