Basic Information
| Provider Information | |||||||||
| NPI: | 1346721073 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSE | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | J | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 SAINT LOUIS AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761043324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173329962 | ||||||||
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| Practice Location | |||||||||
| Address1: | 701 SAINT LOUIS AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761043324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173329962 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2018 | ||||||||
| LastUpdateDate: | 08/21/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 206711 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 206711 | 01 | TX | MANAGED CARE | OTHER | 206711 | 05 | TX | MEDICAID |