Provider Demographics
NPI:1881924652
Name:DEROSA, PETER W (LPC)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:W
Last Name:DEROSA
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:UNCASVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06382-2345
Mailing Address - Country:US
Mailing Address - Phone:860-848-3098
Mailing Address - Fax:860-848-1152
Practice Address - Street 1:20 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:UNCASVILLE
Practice Address - State:CT
Practice Address - Zip Code:06382-2345
Practice Address - Country:US
Practice Address - Phone:860-848-3098
Practice Address - Fax:860-848-1152
Is Sole Proprietor?:No
Enumeration Date:2009-12-30
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT976101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT060966963Medicaid