Provider Demographics
NPI:1104512557
Name:BATES, DESIREE MOMIQUE
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:MOMIQUE
Last Name:BATES
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 1:2239 CRAIG AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95832-1321
Mailing Address - Country:US
Mailing Address - Phone:916-307-7222
Mailing Address - Fax:
Practice Address - Street 1:2239 CRAIG AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95832-1321
Practice Address - Country:US
Practice Address - Phone:916-307-7222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-17
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician