Provider Demographics
NPI:1659371201
Name:DERISO, MIRIAM S (PHD)
Entity Type:Individual
Prefix:DR
First Name:MIRIAM
Middle Name:S
Last Name:DERISO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 S LANG AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15208-2749
Mailing Address - Country:US
Mailing Address - Phone:412-371-8899
Mailing Address - Fax:
Practice Address - Street 1:321 S LANG AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15208-2749
Practice Address - Country:US
Practice Address - Phone:412-371-8899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS007137L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014487710001Medicaid
PA0014487710001Medicaid
PA86000107Medicare PIN