Provider Demographics
NPI:1841966322
Name:DERITIS, PAMELA (LMFT151030)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:DERITIS
Suffix:
Gender:F
Credentials:LMFT151030
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16405 ROSEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-1938
Mailing Address - Country:US
Mailing Address - Phone:714-717-1490
Mailing Address - Fax:
Practice Address - Street 1:16405 ROSEWOOD ST
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-1938
Practice Address - Country:US
Practice Address - Phone:323-380-8857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-17
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA116077106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist