Healthcare Provider Details

I. General information

NPI: 1750210795
Provider Name (Legal Business Name): MIA NOANI ROSALES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 05/15/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10740 W ASHLANDWAY
AVONDALE AZ
85392
US

IV. Provider business mailing address

10740 W ASHLANDWAY
AVONDALE AZ
85392
US

V. Phone/Fax

Practice location:
  • Phone: 602-617-4091
  • Fax:
Mailing address:
  • Phone: 602-617-4091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: