Provider Demographics
NPI:1235770520
Name:DERIENZO, ROSE MARIA (MED, BCBA, LABA)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:MARIA
Last Name:DERIENZO
Suffix:
Gender:F
Credentials:MED, BCBA, LABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 CEDAR CREST DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02324-1208
Mailing Address - Country:US
Mailing Address - Phone:508-631-6431
Mailing Address - Fax:
Practice Address - Street 1:1573 FALL RIVER AVE
Practice Address - Street 2:
Practice Address - City:SEEKONK
Practice Address - State:MA
Practice Address - Zip Code:02771-3740
Practice Address - Country:US
Practice Address - Phone:508-617-8396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2806103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst