Provider Demographics
NPI:1184154916
Name:WIDELL, ROSEANN (MED, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:ROSEANN
Middle Name:
Last Name:WIDELL
Suffix:
Gender:F
Credentials:MED, BCBA, LBA
Other - Prefix:
Other - First Name:ROSEANN
Other - Middle Name:
Other - Last Name:MARQUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED, BCBA, LBA
Mailing Address - Street 1:6239 WOODLAWN AVE N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-5716
Mailing Address - Country:US
Mailing Address - Phone:310-709-3025
Mailing Address - Fax:
Practice Address - Street 1:6239 WOODLAWN AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103
Practice Address - Country:US
Practice Address - Phone:310-709-3025
Practice Address - Fax:206-729-2660
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-14
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
WABA60950253103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician