Provider Demographics
NPI:1659887230
Name:DEROSE, CAMILLE (LPC)
Entity type:Individual
Prefix:
First Name:CAMILLE
Middle Name:
Last Name:DEROSE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 WILSON DR
Mailing Address - Street 2:
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-5216
Mailing Address - Country:US
Mailing Address - Phone:610-304-8347
Mailing Address - Fax:
Practice Address - Street 1:1105 WILSON DR
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-5216
Practice Address - Country:US
Practice Address - Phone:610-304-8347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-19
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC-007701101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty