Provider Demographics
NPI:1629089248
Name:DERISE, KATHLEEN C (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:C
Last Name:DERISE
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 1:205 LAKEWOOD PARK DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-6261
Mailing Address - Country:US
Mailing Address - Phone:757-877-8765
Mailing Address - Fax:
Practice Address - Street 1:12695 MCMANUS BLVD
Practice Address - Street 2:BLDG. 8
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-4435
Practice Address - Country:US
Practice Address - Phone:757-877-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040005341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical