Provider Demographics
NPI:1417183989
Name:DEROSE, TALIA CATHERINE (MSW)
Entity Type:Individual
Prefix:
First Name:TALIA
Middle Name:CATHERINE
Last Name:DEROSE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 5TH ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-4606
Mailing Address - Country:US
Mailing Address - Phone:262-633-1235
Mailing Address - Fax:262-633-1236
Practice Address - Street 1:316 5TH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-4606
Practice Address - Country:US
Practice Address - Phone:262-633-1235
Practice Address - Fax:262-633-1236
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-10
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4827-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional