Provider Demographics
NPI:1851953871
Name:DEROSSO, DOMINIQUE RITA
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:RITA
Last Name:DEROSSO
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 1:434 S 191ST PL
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98148-2000
Mailing Address - Country:US
Mailing Address - Phone:206-910-6712
Mailing Address - Fax:
Practice Address - Street 1:1033 SW 152ND ST
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-1845
Practice Address - Country:US
Practice Address - Phone:206-829-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-29
Last Update Date:2019-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health