Provider Demographics
NPI:1790254530
Name:DEROSA, ELIZABETH ANN (PT)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:ANN
Last Name:DEROSA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7040 RED ARROW HWY
Mailing Address - Street 2:
Mailing Address - City:COLOMA
Mailing Address - State:MI
Mailing Address - Zip Code:49038-8720
Mailing Address - Country:US
Mailing Address - Phone:269-468-4318
Mailing Address - Fax:
Practice Address - Street 1:7040 RED ARROW HWY
Practice Address - Street 2:
Practice Address - City:COLOMA
Practice Address - State:MI
Practice Address - Zip Code:49038-8720
Practice Address - Country:US
Practice Address - Phone:269-468-4318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-23
Last Update Date:2018-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501004377225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist