Provider Demographics
NPI:1952610065
Name:DEROSA, SUSAN (MA, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:DEROSA
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59-180 OLOMANA RD
Mailing Address - Street 2:
Mailing Address - City:KAMUELA
Mailing Address - State:HI
Mailing Address - Zip Code:96743-8517
Mailing Address - Country:US
Mailing Address - Phone:808-333-9733
Mailing Address - Fax:
Practice Address - Street 1:59-180 OLOMANA RD
Practice Address - Street 2:
Practice Address - City:KAMUELA
Practice Address - State:HI
Practice Address - Zip Code:96743-8517
Practice Address - Country:US
Practice Address - Phone:808-333-9733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-07
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HISP-1289235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty