Provider Demographics
NPI:1649081233
Name:BOURASA, ROSALINDA CRUZ
Entity type:Individual
Prefix:
First Name:ROSALINDA
Middle Name:CRUZ
Last Name:BOURASA
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 1:535 MARIAH AVE APT 4303
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2694
Mailing Address - Country:US
Mailing Address - Phone:208-707-3314
Mailing Address - Fax:
Practice Address - Street 1:2265 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-2996
Practice Address - Country:US
Practice Address - Phone:208-524-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-14
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID5371745101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health