Provider Demographics
NPI:1295101574
Name:DEROSE, MICHAEL (LCSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DEROSE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3805B SPRING ST STE 320
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53405-1644
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3805B SPRING ST
Practice Address - Street 2:SUITE 320
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53405-1641
Practice Address - Country:US
Practice Address - Phone:262-687-2222
Practice Address - Fax:262-687-8611
Is Sole Proprietor?:No
Enumeration Date:2015-08-20
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI83191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical