Provider Demographics
NPI:1679139059
Name:ROSE, BETHANIE LASHEA (PTA)
Entity type:Individual
Prefix:
First Name:BETHANIE
Middle Name:LASHEA
Last Name:ROSE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37354-5206
Mailing Address - Country:US
Mailing Address - Phone:423-836-7548
Mailing Address - Fax:
Practice Address - Street 1:262 CHEROKEE PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5153
Practice Address - Country:US
Practice Address - Phone:865-980-0030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-12
Last Update Date:2019-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant