Provider Demographics
NPI:1982043253
Name:DEROSSO, RACHAEL LEIGH
Entity Type:Individual
Prefix:MRS
First Name:RACHAEL
Middle Name:LEIGH
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 1:3723 DEL PRADO BLVD S STE A
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-7124
Mailing Address - Country:US
Mailing Address - Phone:239-896-7302
Mailing Address - Fax:
Practice Address - Street 1:3723 DEL PRADO BLVD S STE A
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-7124
Practice Address - Country:US
Practice Address - Phone:239-540-1155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-20
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health