Provider Demographics
NPI:1023751435
Name:BOTROS, RITA RAMSIS
Entity type:Individual
Prefix:
First Name:RITA
Middle Name:RAMSIS
Last Name:BOTROS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21161 BISON MESA RD APT SUITE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-0025
Mailing Address - Country:US
Mailing Address - Phone:909-997-2195
Mailing Address - Fax:
Practice Address - Street 1:12437 LEWIS ST
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-4673
Practice Address - Country:US
Practice Address - Phone:714-202-0118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-14
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXEP910030476OtherBLUE CALIFORNIA