Provider Demographics
NPI:1417581646
Name:DEROSE, MICHAEL (COTA/L)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DEROSE
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 RIPTIDE CT
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-2105
Mailing Address - Country:US
Mailing Address - Phone:818-414-5593
Mailing Address - Fax:
Practice Address - Street 1:1200 QUAIL ST STE 100
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2706
Practice Address - Country:US
Practice Address - Phone:949-475-1002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5078224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant