Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 160005138 | IL |
NPI | 1003289620 |
---|---|
Provider Name | Mrs. Bridget Rose |
First Address | Carbondale, IL 62901-1246 |
Second Address | Carbondale, IL 62901-1246 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/11/2015 |
Last Update Date | 04/11/2015 |