Provider Demographics
NPI:1427867266
Name:MATOS ROSADA, LIANA
Entity type:Individual
Prefix:
First Name:LIANA
Middle Name:
Last Name:MATOS ROSADA
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 1:1030 BAISDEN RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-4228
Mailing Address - Country:US
Mailing Address - Phone:904-476-9497
Mailing Address - Fax:
Practice Address - Street 1:31 W ADAMS ST APT 608
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32202-3631
Practice Address - Country:US
Practice Address - Phone:904-476-9497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-06
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24393449106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician