Provider Demographics
NPI:1760016653
Name:ROSS, DEJA REGINA MARIE
Entity Type:Individual
Prefix:
First Name:DEJA
Middle Name:REGINA MARIE
Last Name:ROSS
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 1:990 KLAMATH LN STE 20
Mailing Address - Street 2:
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95993-8979
Mailing Address - Country:US
Mailing Address - Phone:916-307-2628
Mailing Address - Fax:
Practice Address - Street 1:990 KLAMATH LN STE 20
Practice Address - Street 2:
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95993-8979
Practice Address - Country:US
Practice Address - Phone:916-307-2628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-28
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician