Provider Demographics
NPI:1558018267
Name:DEANDA, JULISSA JENEA (RBT)
Entity Type:Individual
Prefix:
First Name:JULISSA
Middle Name:JENEA
Last Name:DEANDA
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:926 E 42ND ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-1841
Mailing Address - Country:US
Mailing Address - Phone:325-617-8446
Mailing Address - Fax:
Practice Address - Street 1:4541 N BENTWOOD DR
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-8828
Practice Address - Country:US
Practice Address - Phone:325-939-2650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-03
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-22-200206106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician