Provider Demographics
NPI:1912320011
Name:DEROSE, DEREK
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:
Last Name:DEROSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 PLEASANT VIEW RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CHINA
Mailing Address - State:ME
Mailing Address - Zip Code:04358-4420
Mailing Address - Country:US
Mailing Address - Phone:207-620-6544
Mailing Address - Fax:
Practice Address - Street 1:680 PLEASANT VIEW RIDGE RD
Practice Address - Street 2:
Practice Address - City:CHINA
Practice Address - State:ME
Practice Address - Zip Code:04358-4420
Practice Address - Country:US
Practice Address - Phone:207-620-6544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-24
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4186225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist