Provider Demographics
NPI:1710490347
Name:PALACIOS, ROSSIO
Entity Type:Individual
Prefix:
First Name:ROSSIO
Middle Name:
Last Name:PALACIOS
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 1:11770 BERNARDO PLAZA CT STE 116
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-2423
Mailing Address - Country:US
Mailing Address - Phone:760-483-4325
Mailing Address - Fax:
Practice Address - Street 1:11770 BERNARDO PLAZA CT STE 116
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2423
Practice Address - Country:US
Practice Address - Phone:760-483-4325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-06
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA1-20-41312103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician