Healthcare Provider Details

I. General information

NPI: 1831868223
Provider Name (Legal Business Name): AMELIA JANE ROESNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2021
Last Update Date: 09/08/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3745 LONG BEACH BLVD
LONG BEACH CA
90807-3340
US

IV. Provider business mailing address

PO BOX 399318
SAN FRANCISCO CA
94139-9318
US

V. Phone/Fax

Practice location:
  • Phone: 866-523-4268
  • Fax:
Mailing address:
  • Phone: 866-523-4268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: