Provider Demographics
NPI:1265626386
Name:DEROSA, RENEE LOUISE (MSW)
Entity type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:LOUISE
Last Name:DEROSA
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 N MAIN ST
Mailing Address - Street 2:SUITE # 305
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1625
Mailing Address - Country:US
Mailing Address - Phone:574-234-3515
Mailing Address - Fax:574-234-3565
Practice Address - Street 1:108 N MAIN ST
Practice Address - Street 2:SUITE # 305
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1625
Practice Address - Country:US
Practice Address - Phone:574-234-3515
Practice Address - Fax:574-234-3565
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-31
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker