Provider Demographics
NPI:1679608657
Name:ROSE, ELIZABETH (OTR)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3565 AUSTELL RD SW
Mailing Address - Street 2:SUITE 11
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30008-5769
Mailing Address - Country:US
Mailing Address - Phone:770-319-8000
Mailing Address - Fax:770-319-8730
Practice Address - Street 1:3565 AUSTELL RD SW
Practice Address - Street 2:SUITE 11
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30008-5769
Practice Address - Country:US
Practice Address - Phone:770-319-8000
Practice Address - Fax:770-319-8730
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT001074225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics