Provider Demographics
NPI:1437470747
Name:PRENDERGAST, ROSALIE BYRD (BCBA)
Entity Type:Individual
Prefix:
First Name:ROSALIE
Middle Name:BYRD
Last Name:PRENDERGAST
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2091 KERR GULCH RD
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-6398
Mailing Address - Country:US
Mailing Address - Phone:720-339-1309
Mailing Address - Fax:303-279-6181
Practice Address - Street 1:2091 KERR GULCH RD
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-6398
Practice Address - Country:US
Practice Address - Phone:720-339-1309
Practice Address - Fax:303-279-6181
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-21
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-09-5801103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst