Provider Demographics
NPI:1386864742
Name:DEROSA, CHERYL A (LCSW, CASAC)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:A
Last Name:DEROSA
Suffix:
Gender:F
Credentials:LCSW, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-2212
Mailing Address - Country:US
Mailing Address - Phone:607-763-2749
Mailing Address - Fax:607-763-2762
Practice Address - Street 1:114 CLINTON ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-2212
Practice Address - Country:US
Practice Address - Phone:607-763-2749
Practice Address - Fax:607-763-2762
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20264101YA0400X
NY081645-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY20264OtherCASAC-T CERTIFICATE #
NY081645-1OtherUNIVERSITY OF THE STATE OF NEW YORK EDUCATION DEPARTMENT