Provider Demographics
NPI:1104451723
Name:ROSAMORE, DESIRAYE NICOLE (BCBA)
Entity type:Individual
Prefix:
First Name:DESIRAYE
Middle Name:NICOLE
Last Name:ROSAMORE
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6303 SIENNA RANCH RD APT 1108
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-4884
Mailing Address - Country:US
Mailing Address - Phone:337-540-0778
Mailing Address - Fax:
Practice Address - Street 1:4638 RIVERSTONE BLVD
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-6157
Practice Address - Country:US
Practice Address - Phone:281-969-7527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-04
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3289103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst