Provider Demographics
NPI:1487847414
Name:DERUSSI, ALIDA ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:ALIDA
Middle Name:ANN
Last Name:DERUSSI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:HAWORTH
Mailing Address - State:NJ
Mailing Address - Zip Code:07641-1727
Mailing Address - Country:US
Mailing Address - Phone:201-384-0186
Mailing Address - Fax:201-384-0186
Practice Address - Street 1:455 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:HAWORTH
Practice Address - State:NJ
Practice Address - Zip Code:07641-1727
Practice Address - Country:US
Practice Address - Phone:201-384-0186
Practice Address - Fax:201-384-0186
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-22
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY064751104100000X
NJ44SC052492001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
3805750OtherAETNA
7750693OtherAETNA
NJ788115000OtherMAGELLAN
NJP3513999OtherOXFORD
NJP3513999OtherOXFORD
7750693OtherAETNA