Provider Demographics
NPI:1780926469
Name:DEROSA, SUSAN M (PT)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:M
Last Name:DEROSA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 ELIZABETH LN
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:NH
Mailing Address - Zip Code:03079-1348
Mailing Address - Country:US
Mailing Address - Phone:603-894-5170
Mailing Address - Fax:
Practice Address - Street 1:166 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-1910
Practice Address - Country:US
Practice Address - Phone:978-722-0177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-20
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5324225100000X
NH1541225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist