Provider Demographics
NPI:1912025826
Name:DEROSE, LUCILLE RENEE (PTA)
Entity Type:Individual
Prefix:
First Name:LUCILLE
Middle Name:RENEE
Last Name:DEROSE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1228 COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:NEWFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08344-9605
Mailing Address - Country:US
Mailing Address - Phone:856-692-2349
Mailing Address - Fax:
Practice Address - Street 1:551 W LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:HAVERFORD
Practice Address - State:PA
Practice Address - Zip Code:19041-1419
Practice Address - Country:US
Practice Address - Phone:180-055-0921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00091900225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant