Provider Demographics
NPI:1548947989
Name:DE LA ROSA, SIMON ISAAC (LMT/CMT)
Entity type:Individual
Prefix:
First Name:SIMON
Middle Name:ISAAC
Last Name:DE LA ROSA
Suffix:
Gender:M
Credentials:LMT/CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 HEMISFAIR BLVD APT 611
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78205-3354
Mailing Address - Country:US
Mailing Address - Phone:210-889-4635
Mailing Address - Fax:
Practice Address - Street 1:623 HEMISFAIR BLVD APT 611
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78205-3354
Practice Address - Country:US
Practice Address - Phone:210-889-4635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA84708225700000X
TXMT130587225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist