Healthcare Provider Details

I. General information

NPI: 1851618870
Provider Name (Legal Business Name): DAVID W ROSE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2010
Last Update Date: 08/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 HILLCROFT DR
ROCKWALL TX
75087-2368
US

IV. Provider business mailing address

1930 HILLCROFT DR
ROCKWALL TX
75087-2368
US

V. Phone/Fax

Practice location:
  • Phone: 972-800-0892
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number34564
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number34564
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number34564
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number34564
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number34564
License Number StateTX
# 6
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number34564
License Number StateTX
# 7
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number34564
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: