Provider Demographics
NPI:1174562607
Name:ROSE, REBECCA DENISE (OT)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:DENISE
Last Name:ROSE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 JOHNSTON ST SE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-2515
Mailing Address - Country:US
Mailing Address - Phone:256-340-9708
Mailing Address - Fax:256-340-9624
Practice Address - Street 1:1701 MAIN AVE SW
Practice Address - Street 2:SUITE G
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35055-5299
Practice Address - Country:US
Practice Address - Phone:256-775-3737
Practice Address - Fax:256-775-3738
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALOT2427174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529917620Medicaid
AL1003819608OtherGROUP NPI
AL529917620Medicaid