Provider Demographics
NPI:1578822060
Name:DEROSA, GINA JO-ANN (LICSW)
Entity Type:Individual
Prefix:MISS
First Name:GINA
Middle Name:JO-ANN
Last Name:DEROSA
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890-1446
Mailing Address - Country:US
Mailing Address - Phone:781-756-2000
Mailing Address - Fax:781-756-7529
Practice Address - Street 1:41 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:MA
Practice Address - Zip Code:01890-1446
Practice Address - Country:US
Practice Address - Phone:781-756-2000
Practice Address - Fax:781-756-7529
Is Sole Proprietor?:No
Enumeration Date:2012-05-03
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1550851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical