Provider Demographics
NPI:1245726348
Name:FRAYA, SHINTA DESENTIA (RBT)
Entity type:Individual
Prefix:MS
First Name:SHINTA
Middle Name:DESENTIA
Last Name:FRAYA
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 GRANDE WAY STE B
Mailing Address - Street 2:
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-4182
Mailing Address - Country:US
Mailing Address - Phone:760-792-3089
Mailing Address - Fax:
Practice Address - Street 1:123 GRANDE WAY STE B
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555
Practice Address - Country:US
Practice Address - Phone:760-792-3089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-02
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
BACB402765106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
BACB402765OtherBEHAVIOR ANALYST CERTIFICATION BOARD
RBT-18-59780OtherBEHAVIOR ANALYST CERTIFICATION BOARD