Healthcare Provider Details

I. General information

NPI: 1184154916
Provider Name (Legal Business Name): ROSEANN WIDELL M.ED., BCBA, LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ROSEANN MARQUEZ M.ED., BCBA, LBA

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 04/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6239 WOODLAWN AVE N
SEATTLE WA
98103
US

IV. Provider business mailing address

6239 WOODLAWN AVE N
SEATTLE WA
98103-5716
US

V. Phone/Fax

Practice location:
  • Phone: 310-709-3025
  • Fax: 206-729-2660
Mailing address:
  • Phone: 310-709-3025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBA60950253
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: