Provider Demographics
NPI:1972756922
Name:DA GAMA ROSE, AMBER D (PT)
Entity type:Individual
Prefix:MS
First Name:AMBER
Middle Name:D
Last Name:DA GAMA ROSE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:D
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:35 EXECUTIVE PLAZA CT
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-5838
Mailing Address - Country:US
Mailing Address - Phone:618-226-8277
Mailing Address - Fax:618-228-4481
Practice Address - Street 1:35 EXECUTIVE PLAZA CT
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5838
Practice Address - Country:US
Practice Address - Phone:618-226-8277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-03
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012212225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist