Provider Demographics
NPI:1578238192
Name:DEROSA, ANGELIQUE
Entity Type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:
Last Name:DEROSA
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 1:99 BEAVER DAM RD
Mailing Address - Street 2:
Mailing Address - City:ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11751-1903
Mailing Address - Country:US
Mailing Address - Phone:631-942-3661
Mailing Address - Fax:
Practice Address - Street 1:99 BEAVER DAM RD
Practice Address - Street 2:
Practice Address - City:ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11751-1903
Practice Address - Country:US
Practice Address - Phone:631-942-3661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty