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General NPI Number Information
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NPI Number | 1386313625
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Entity Type | Individual
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Provider Name | BETHIAH DEMAY ROSA
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Gender | Female
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Dates
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Enumeration Date | 09/09/2021
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Last Update Date | 09/09/2021
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Provider Practice Location Address
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Address Line | 3654 GRAND AVE
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City | OAKLAND
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State | CA
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Zip | 94610-2008
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Country | US
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Telephone | 518-965-2387
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Fax |
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Provider Business Mailing Address
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Address Line | 2925 MAGNOLIA ST APT B
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City | OAKLAND
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State | CA
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Zip | 94608-4413
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Country | US
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Telephone | 518-965-2387
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 77617
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License Number State | CA
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