Provider Demographics
NPI:1437423563
Name:DEROSE FAMILY COUNSELING, LLC.
Entity Type:Organization
Organization Name:DEROSE FAMILY COUNSELING, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TALIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEROSE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:262-633-1235
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-07
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2958251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health