Provider Demographics
NPI:1801388442
Name:DEROSA, DANIEL PAUL (MS, BS, RBT)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:PAUL
Last Name:DEROSA
Suffix:
Gender:M
Credentials:MS, BS, RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1N754 REDBUD LN
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-2027
Mailing Address - Country:US
Mailing Address - Phone:773-858-2598
Mailing Address - Fax:
Practice Address - Street 1:27555 DIEHL RD
Practice Address - Street 2:
Practice Address - City:WARRENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60555-3849
Practice Address - Country:US
Practice Address - Phone:630-355-6533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL17-42325106S00000X
IL21-175436106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician