Healthcare Provider Details

I. General information

NPI: 1720577471
Provider Name (Legal Business Name): EMILY ROSE VAJIRASARN OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2018
Last Update Date: 05/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 N WASHINGTON AVE STE 4000
DALLAS TX
75246-1776
US

IV. Provider business mailing address

411 N WASHINGTON AVE STE 4000
DALLAS TX
75246-1776
US

V. Phone/Fax

Practice location:
  • Phone: 214-820-7457
  • Fax:
Mailing address:
  • Phone: 214-820-7457
  • Fax: 214-820-1654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number118962
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: