Provider Demographics
NPI:1578011243
Name:DESLANDES, ROSIE
Entity Type:Individual
Prefix:
First Name:ROSIE
Middle Name:
Last Name:DESLANDES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3460 MEANDERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-9616
Mailing Address - Country:US
Mailing Address - Phone:330-301-8068
Mailing Address - Fax:
Practice Address - Street 1:615 CHURCHILL HUBBARD RD
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44505
Practice Address - Country:US
Practice Address - Phone:330-301-8068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.1101564-SUPV104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0184331Medicaid