Provider Demographics
NPI:1033433602
Name:ROSEN, DEREK THOMAS (MA/LLP)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:THOMAS
Last Name:ROSEN
Suffix:
Gender:M
Credentials:MA/LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18781 HANNAN RD
Mailing Address - Street 2:
Mailing Address - City:NEW BOSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48164-9368
Mailing Address - Country:US
Mailing Address - Phone:734-642-5523
Mailing Address - Fax:
Practice Address - Street 1:9315 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48239-1260
Practice Address - Country:US
Practice Address - Phone:180-045-0450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-25
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014393103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist