Provider Demographics
NPI:1770845620
Name:DERVISEVIC REZIKA, SAMIRA (MSED, BCBA, NYS LBA)
Entity type:Individual
Prefix:MRS
First Name:SAMIRA
Middle Name:
Last Name:DERVISEVIC REZIKA
Suffix:
Gender:F
Credentials:MSED, BCBA, NYS LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2324 JEROME AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-2801
Mailing Address - Country:US
Mailing Address - Phone:917-518-4266
Mailing Address - Fax:
Practice Address - Street 1:2324 JEROME AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-2801
Practice Address - Country:US
Practice Address - Phone:718-646-7410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-15
Last Update Date:2024-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1176658174400000X
NY002145103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No174400000XOther Service ProvidersSpecialist