Provider Demographics
NPI:1841604923
Name:DEROSA, GERI NICOLE (DPT)
Entity Type:Individual
Prefix:
First Name:GERI
Middle Name:NICOLE
Last Name:DEROSA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:GERI
Other - Middle Name:
Other - Last Name:MALDONADO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1377 MOTOR PKWY STE 307
Mailing Address - Street 2:
Mailing Address - City:ISLANDIA
Mailing Address - State:NY
Mailing Address - Zip Code:11749-5258
Mailing Address - Country:US
Mailing Address - Phone:631-580-5200
Mailing Address - Fax:
Practice Address - Street 1:80 MILL ST STE 1
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:NJ
Practice Address - Zip Code:07860-1411
Practice Address - Country:US
Practice Address - Phone:973-940-7311
Practice Address - Fax:973-940-7342
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01549300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist