Healthcare Provider Details

I. General information

NPI: 1265525927
Provider Name (Legal Business Name): MARY W ROSE PSY.D, C.B.S.M
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 08/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N TEXAS AVENUE SUITE B
WEBSTER TX
77598
US

IV. Provider business mailing address

400 N. TEXAS AVENUE SUITE B
WEBSTER TX
77598
US

V. Phone/Fax

Practice location:
  • Phone: 281-316-8400
  • Fax: 281-318-8410
Mailing address:
  • Phone: 281-316-8400
  • Fax: 281-318-8410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number31557
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code173F00000X
TaxonomySleep Specialist (PhD)
License Number3-1557
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: