Healthcare Provider Details

I. General information

NPI: 1578049300
Provider Name (Legal Business Name): ROSY REYNOSO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2018
Last Update Date: 07/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

93 MAYFIELD ST
WORCESTER MA
01602-3427
US

IV. Provider business mailing address

93 MAYFIELD ST
WORCESTER MA
01602-3427
US

V. Phone/Fax

Practice location:
  • Phone: 508-797-2472
  • Fax:
Mailing address:
  • Phone: 508-798-2472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100018603058
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerMASSHEALTH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: