Provider Demographics
NPI:1760990600
Name:AMAT-ROGERS, MARISSA ROSE (MS BCBA)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:ROSE
Last Name:AMAT-ROGERS
Suffix:
Gender:F
Credentials:MS BCBA
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:ROSE
Other - Last Name:AMAT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS BCBA
Mailing Address - Street 1:4455 MURPHY CANYON RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4379
Mailing Address - Country:US
Mailing Address - Phone:619-873-7067
Mailing Address - Fax:619-639-8277
Practice Address - Street 1:4455 MURPHY CANYON RD STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4379
Practice Address - Country:US
Practice Address - Phone:619-873-7067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-12
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19-85711106S00000X
CA1-23-69422103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA19-85711OtherRBT