Provider Demographics
NPI:1053083212
Name:DEROSENA, JUDY (MED,LAC, NCC)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:
Last Name:DEROSENA
Suffix:
Gender:F
Credentials:MED,LAC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 CANNON ST
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-3646
Mailing Address - Country:US
Mailing Address - Phone:718-308-1101
Mailing Address - Fax:
Practice Address - Street 1:1135 CLIFTON AVE STE 207
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-3643
Practice Address - Country:US
Practice Address - Phone:973-988-4241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-05
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00524800101YM0800X
NJ37PC00943700101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health