Provider Demographics
NPI:1750636643
Name:DEROSA, JOHN DAVID (BS, CADCII)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:DEROSA
Suffix:
Gender:M
Credentials:BS, CADCII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90805-5924
Mailing Address - Country:US
Mailing Address - Phone:562-428-4222
Mailing Address - Fax:562-428-0372
Practice Address - Street 1:100 E MARKET ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90805-5924
Practice Address - Country:US
Practice Address - Phone:562-428-4222
Practice Address - Fax:562-428-0372
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA7071011101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)