Provider Demographics
NPI:1083737902
Name:DEROSA, MARY ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY ANN
Middle Name:
Last Name:DEROSA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 VIRGINIA RD
Mailing Address - Street 2:
Mailing Address - City:MONTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07045-9209
Mailing Address - Country:US
Mailing Address - Phone:973-299-9868
Mailing Address - Fax:973-299-9868
Practice Address - Street 1:9 VIRGINIA RD
Practice Address - Street 2:
Practice Address - City:MONTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07045-9209
Practice Address - Country:US
Practice Address - Phone:973-299-9868
Practice Address - Fax:973-299-9868
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35S100371200103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical