Provider Demographics
NPI:1689767741
Name:GENIESER-DEROSA, ANYA (PSYD)
Entity Type:Individual
Prefix:
First Name:ANYA
Middle Name:
Last Name:GENIESER-DEROSA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1848 CANDLEWYCK LN
Mailing Address - Street 2:
Mailing Address - City:GREEN LANE
Mailing Address - State:PA
Mailing Address - Zip Code:18054-2047
Mailing Address - Country:US
Mailing Address - Phone:484-624-2415
Mailing Address - Fax:215-679-2875
Practice Address - Street 1:80 GRAVEL PIKE UNIT B
Practice Address - Street 2:
Practice Address - City:RED HILL
Practice Address - State:PA
Practice Address - Zip Code:18076-1428
Practice Address - Country:US
Practice Address - Phone:484-624-2415
Practice Address - Fax:215-679-2875
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TB0200X, 103TC2200X, 103TP2701X, 174400000X
PAPS015501103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPS015501OtherLICENSE
PA084366XTGMedicare PIN