Provider Demographics
NPI:1952976128
Name:ROSA, BERENIS
Entity Type:Individual
Prefix:
First Name:BERENIS
Middle Name:
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 1:6426 W RIVERCHASE DR BLDG 33
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-5658
Mailing Address - Country:US
Mailing Address - Phone:718-764-9423
Mailing Address - Fax:
Practice Address - Street 1:6426 W RIVERCHASE DR BLDG 33
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33637-5658
Practice Address - Country:US
Practice Address - Phone:718-764-9423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYUB30302WMedicaid