Provider Demographics
NPI:1255598355
Name:DEROSIA, TAMARA M (LCMHC)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:M
Last Name:DEROSIA
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:FAIR HAVEN
Mailing Address - State:VT
Mailing Address - Zip Code:05743-1238
Mailing Address - Country:US
Mailing Address - Phone:802-265-3558
Mailing Address - Fax:
Practice Address - Street 1:912 ROUTE 4A W STE 2
Practice Address - Street 2:
Practice Address - City:HYDEVILLE
Practice Address - State:VT
Practice Address - Zip Code:05750-9700
Practice Address - Country:US
Practice Address - Phone:802-558-3477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-18
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0680000742101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health