Provider Demographics
NPI:1194281048
Name:ROSALES, BERNY A
Entity type:Individual
Prefix:
First Name:BERNY
Middle Name:A
Last Name:ROSALES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 LLEWELLYN AVE
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-1940
Mailing Address - Country:US
Mailing Address - Phone:408-379-3790
Mailing Address - Fax:
Practice Address - Street 1:251 LLEWELLYN AVE
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-1940
Practice Address - Country:US
Practice Address - Phone:408-379-3790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-15
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46-1305562106S00000X
172V00000X
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No172V00000XOther Service ProvidersCommunity Health Worker