Provider Demographics
NPI:1265525927
Name:ROSE, MARY W (PSYD, CBSM)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:W
Last Name:ROSE
Suffix:
Gender:F
Credentials:PSYD, CBSM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N. TEXAS AVENUE
Mailing Address - Street 2:SUITE B
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598
Mailing Address - Country:US
Mailing Address - Phone:281-316-8400
Mailing Address - Fax:281-318-8410
Practice Address - Street 1:400 N TEXAS AVENUE
Practice Address - Street 2:SUITE B
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598
Practice Address - Country:US
Practice Address - Phone:281-316-8400
Practice Address - Fax:281-318-8410
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31557103TC0700X
TX3-1557173F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173F00000XOther Service ProvidersSleep Specialist, PhD
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX147062701Medicaid
TX8B5936Medicare PIN
TX147062701Medicaid