Healthcare Provider Details

I. General information

NPI: 1144633827
Provider Name (Legal Business Name): SAMANTHA DEROSE BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2014
Last Update Date: 11/28/2023
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 E HEIM AVE STE 205
ORANGE CA
92865-3016
US

IV. Provider business mailing address

1815 E HEIM AVE STE 205
ORANGE CA
92865-3016
US

V. Phone/Fax

Practice location:
  • Phone: 714-640-6891
  • Fax:
Mailing address:
  • Phone: 171-640-6891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-17-29118
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: