Provider Demographics
NPI:1255932067
Name:DEGOUT, ROSA E (STUDENT)
Entity type:Individual
Prefix:
First Name:ROSA
Middle Name:E
Last Name:DEGOUT
Suffix:
Gender:F
Credentials:STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:439 S UNION ST STE 404
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01843-2844
Mailing Address - Country:US
Mailing Address - Phone:978-968-7719
Mailing Address - Fax:978-681-8354
Practice Address - Street 1:439 S UNION ST STE 404
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01843-2844
Practice Address - Country:US
Practice Address - Phone:978-968-7719
Practice Address - Fax:978-681-8354
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-06
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health