MEDICARE: CLARISSA ROGERS OTD, OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XP0200X	Pediatric Occupational Therapist	122180	TX

General Provider Information

NPI Number	:	1104512896
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLARISSA ROGERS OTD, OTR/L

Provider Business Mailing Address
First Line	:	159 LIMERICK RD
Second Line	:
City	:	BUDA
State	:	TX
Zip	:	78610-2080
Country	:	US
Telephone Number	:	956-463-3356
Fax Number	:

Provider Business Practice Location Address
First Line	:	2009 S WALNUT AVE STE 103
Second Line	:
City	:	NEW BRAUNFELS
State	:	TX
Zip	:	78130-2364
Country	:	US
Telephone Number	:	830-507-1285
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2023
Last Update Date	:	04/14/2023

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