Provider Demographics
NPI:1629268222
Name:DEROSA, PATTY E (LCPC)
Entity Type:Individual
Prefix:
First Name:PATTY
Middle Name:E
Last Name:DEROSA
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1609
Mailing Address - Street 2:
Mailing Address - City:HAVRE
Mailing Address - State:MT
Mailing Address - Zip Code:59501-1609
Mailing Address - Country:US
Mailing Address - Phone:406-265-4296
Mailing Address - Fax:406-494-1724
Practice Address - Street 1:601 14TH ST.
Practice Address - Street 2:
Practice Address - City:HAVRE
Practice Address - State:MT
Practice Address - Zip Code:59501-5333
Practice Address - Country:US
Practice Address - Phone:406-265-9671
Practice Address - Fax:406-265-8460
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT962101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT962OtherSTATE OF MONTANA LICENSE