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General NPI Number Information
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NPI Number | 1407124258
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Entity Type | Individual
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Provider Name | SUSANNE DEROSSITTE BELK BCBA
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Gender | Female
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Dates
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Enumeration Date | 12/08/2011
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Last Update Date | 12/08/2011
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Provider Practice Location Address
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Address Line | 3114 FOX RD STE A
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City | JONESBORO
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State | AR
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Zip | 72404-9577
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Country | US
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Telephone | 870-203-0296
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Fax |
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Provider Business Mailing Address
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Address Line | 4600 PETER TRL
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City | JONESBORO
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State | AR
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Zip | 72401-7954
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Country | US
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Telephone | 870-761-4711
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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 | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | 1-09-5322
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License Number State | AR
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