=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679728513
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARY WILCOX ROSE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2008
-----------------------------------------------------
Last Update Date | 03/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10019 MAIN ST STE A9
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77025-5257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-822-1463
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3139 W HOLCOMBE BLVD # 364
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77025-1505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-822-1463
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL PSYCH/SLEEP SPECIALIST
-----------------------------------------------------
Name | DR. MARY W ROSE
-----------------------------------------------------
Credential | PSYD, CBSM
-----------------------------------------------------
Telephone | 713-822-1463
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 31557
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------