Provider Demographics
NPI:1205405651
Name:DEROSIA, KAYA TALA
Entity type:Individual
Prefix:
First Name:KAYA
Middle Name:TALA
Last Name:DEROSIA
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 1:114 ROBBINS ST
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-3351
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24681 NORTHWESTERN HWY STE 2006
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2305
Practice Address - Country:US
Practice Address - Phone:770-373-5822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-21
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst