Provider Demographics
NPI:1023570058
Name:ROSAS-BUENROSTRO, LIDIA JAZMIN
Entity Type:Individual
Prefix:
First Name:LIDIA
Middle Name:JAZMIN
Last Name:ROSAS-BUENROSTRO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1328 WALLIS AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-6537
Mailing Address - Country:US
Mailing Address - Phone:805-264-0002
Mailing Address - Fax:
Practice Address - Street 1:1328 WALLIS AVE
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93458-6537
Practice Address - Country:US
Practice Address - Phone:805-264-0002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-31
Last Update Date:2019-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician