=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285190496
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHLEEN GRACE ROSENBAUM COTA/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2019
-----------------------------------------------------
Last Update Date | 02/12/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 165 JOHNSON CIR
-----------------------------------------------------
City | LOCKESBURG
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71846-9032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-557-6102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 165 JOHNSON CIR
-----------------------------------------------------
City | LOCKESBURG
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71846-9032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-557-6102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number | 215592
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | 215592
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------