Provider Demographics
NPI:1316277148
Name:ROSE, MARY KAY (PTA)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KAY
Last Name:ROSE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:P.O. BOX 209036
Mailing Address - Street 2:SHRINERS HOSPITALS FOR CHILDREN R TWIN CITIES
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-9036
Mailing Address - Country:US
Mailing Address - Phone:813-281-8478
Mailing Address - Fax:813-281-8113
Practice Address - Street 1:215 RADIO DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-5815
Practice Address - Country:US
Practice Address - Phone:612-596-6100
Practice Address - Fax:612-339-5954
Is Sole Proprietor?:No
Enumeration Date:2009-12-29
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNA1132225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant