Provider Demographics
NPI:1972568921
Name:DEROSA, MICHAEL NEIL (LICSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:NEIL
Last Name:DEROSA
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:WESTERLY
Mailing Address - State:RI
Mailing Address - Zip Code:02891-3432
Mailing Address - Country:US
Mailing Address - Phone:401-855-0071
Mailing Address - Fax:
Practice Address - Street 1:101 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:WESTERLY
Practice Address - State:RI
Practice Address - Zip Code:02891-3432
Practice Address - Country:US
Practice Address - Phone:401-855-0071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW014951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical