Provider Demographics
NPI:1194031849
Name:DEROSA, SUZANNE (LPC)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:DEROSA
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 ARVIDA RD
Mailing Address - Street 2:
Mailing Address - City:WOLCOTT
Mailing Address - State:CT
Mailing Address - Zip Code:06716-2766
Mailing Address - Country:US
Mailing Address - Phone:203-509-8244
Mailing Address - Fax:
Practice Address - Street 1:43 SHERMAN HILL RD STE 103
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:CT
Practice Address - Zip Code:06798-3651
Practice Address - Country:US
Practice Address - Phone:203-509-8244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001350101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1194031849Medicaid