Provider Demographics
NPI:1780192591
Name:ESPARZA, CHARISSE ELLEENE (BCABA)
Entity Type:Individual
Prefix:
First Name:CHARISSE
Middle Name:ELLEENE
Last Name:ESPARZA
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:CHARISSE
Other - Middle Name:ELLEENE
Other - Last Name:DEMING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2011 N PINE GROVE CT
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-5019
Mailing Address - Country:US
Mailing Address - Phone:562-447-7061
Mailing Address - Fax:
Practice Address - Street 1:8100 E 22ND ST N STE 1600-B
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-2321
Practice Address - Country:US
Practice Address - Phone:316-613-3543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-15
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0-21-11885106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst