Provider Demographics
NPI:1235697970
Name:ROSS, DEIANIA MARIE
Entity Type:Individual
Prefix:
First Name:DEIANIA
Middle Name:MARIE
Last Name:ROSS
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 1:14643 KIMBERLY ST
Mailing Address - Street 2:
Mailing Address - City:ADELANTO
Mailing Address - State:CA
Mailing Address - Zip Code:92301-3840
Mailing Address - Country:US
Mailing Address - Phone:562-508-6953
Mailing Address - Fax:
Practice Address - Street 1:14643 KIMBERLY ST
Practice Address - Street 2:
Practice Address - City:ADELANTO
Practice Address - State:CA
Practice Address - Zip Code:92301-3840
Practice Address - Country:US
Practice Address - Phone:562-508-6953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician