Provider Demographics
NPI:1356358071
Name:DERISO, SUSAN G (LSW CEAP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:G
Last Name:DERISO
Suffix:
Gender:F
Credentials:LSW CEAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 PITTSBURGH STREET
Mailing Address - Street 2:P.O. BOX 1285
Mailing Address - City:MARS
Mailing Address - State:PA
Mailing Address - Zip Code:16046-3018
Mailing Address - Country:US
Mailing Address - Phone:724-625-9450
Mailing Address - Fax:724-625-9456
Practice Address - Street 1:508 PITTSBURGH STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:MARS
Practice Address - State:PA
Practice Address - Zip Code:16046-3018
Practice Address - Country:US
Practice Address - Phone:724-625-9450
Practice Address - Fax:724-625-9456
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW-002275E1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical