Healthcare Provider Details

I. General information

NPI: 1225847882
Provider Name (Legal Business Name): ROSA MARIE DEJESUS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2025
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51111 WOODWARD AVE STE 150
PONTIAC MI
48342-5037
US

IV. Provider business mailing address

431 N SAGINAW ST
PONTIAC MI
48342-1459
US

V. Phone/Fax

Practice location:
  • Phone: 248-254-2616
  • Fax:
Mailing address:
  • Phone: 248-653-9558
  • 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: