Provider Demographics
NPI:1083155410
Name:DEROSE, CRYSTAL
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:DEROSE
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 1:306 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:PA
Mailing Address - Zip Code:17512-2137
Mailing Address - Country:US
Mailing Address - Phone:717-560-3782
Mailing Address - Fax:717-560-3787
Practice Address - Street 1:306 N 7TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:PA
Practice Address - Zip Code:17512-2137
Practice Address - Country:US
Practice Address - Phone:717-560-3782
Practice Address - Fax:717-560-3787
Is Sole Proprietor?:No
Enumeration Date:2017-03-18
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC008595101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional