Healthcare Provider Details

I. General information

NPI: 1134906456
Provider Name (Legal Business Name): ALEXANDRA B ROSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2023
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3104 SKINNER MILL RD
AUGUSTA GA
30909-1968
US

IV. Provider business mailing address

1209 SUMMERHILL RD
NORTH AUGUSTA SC
29841-3039
US

V. Phone/Fax

Practice location:
  • Phone: 706-522-4222
  • Fax:
Mailing address:
  • Phone: 706-306-6119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT007523
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: