Provider Demographics
NPI:1386011765
Name:DE LA ROSA, BETSY R (MA, CFY-SLP)
Entity Type:Individual
Prefix:MS
First Name:BETSY
Middle Name:R
Last Name:DE LA ROSA
Suffix:
Gender:F
Credentials:MA, CFY-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 LIND AVE SW
Mailing Address - Street 2:SUITE 100 ATTN CREDENTIALING
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-4970
Mailing Address - Country:US
Mailing Address - Phone:425-690-2715
Mailing Address - Fax:
Practice Address - Street 1:3600 LIND AVE SW STE 160
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-4934
Practice Address - Country:US
Practice Address - Phone:425-690-3513
Practice Address - Fax:425-690-9513
Is Sole Proprietor?:No
Enumeration Date:2015-09-01
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL61033853235Z00000X
MN9560235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA215572Medicaid