Provider Demographics
NPI:1215468137
Name:ROSE, MARTHA (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:669 AIRPORT FWY
Mailing Address - Street 2:SUITE 302
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053-3970
Mailing Address - Country:US
Mailing Address - Phone:817-653-5888
Mailing Address - Fax:
Practice Address - Street 1:669 AIRPORT FWY
Practice Address - Street 2:SUITE 302
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76053-3970
Practice Address - Country:US
Practice Address - Phone:817-653-5888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-22
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36721103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX475145044OtherEIN