Provider Demographics
NPI:1821649823
Name:ROSA, GLORY MATY
Entity Type:Individual
Prefix:
First Name:GLORY
Middle Name:MATY
Last Name:ROSA
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 1:17954 SW 33RD CT
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33029-1636
Mailing Address - Country:US
Mailing Address - Phone:305-726-3750
Mailing Address - Fax:
Practice Address - Street 1:17954 SW 33RD CT
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33029-1636
Practice Address - Country:US
Practice Address - Phone:305-726-3750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB-19-188940106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician