Provider Demographics
NPI:1851767289
Name:DERISO, KATHERINE
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:DERISO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 NIAGARA ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14201-1886
Mailing Address - Country:US
Mailing Address - Phone:168-531-3357
Mailing Address - Fax:716-853-1598
Practice Address - Street 1:430 NIAGARA ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14201-1886
Practice Address - Country:US
Practice Address - Phone:716-853-1335
Practice Address - Fax:716-853-1598
Is Sole Proprietor?:No
Enumeration Date:2015-08-20
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008985101YM0800X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health