Provider Demographics
NPI:1033990098
Name:DERAS, ROSA
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:
Last Name:DERAS
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 1:1009 COLLEEN CT
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-5931
Mailing Address - Country:US
Mailing Address - Phone:818-322-9138
Mailing Address - Fax:
Practice Address - Street 1:2811 PENNSYLVANIA AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-3865
Practice Address - Country:US
Practice Address - Phone:202-894-6811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-06
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCCACII1372101YA0400X
171M00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator