Healthcare Provider Details

I. General information

NPI: 1356358071
Provider Name (Legal Business Name): SUSAN G DERISO LSW CEAP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 PITTSBURGH STREET SUITE 100
MARS PA
16046-3018
US

IV. Provider business mailing address

508 PITTSBURGH STREET P.O. BOX 1285
MARS PA
16046-3018
US

V. Phone/Fax

Practice location:
  • Phone: 724-625-9450
  • Fax: 724-625-9456
Mailing address:
  • Phone: 724-625-9450
  • Fax: 724-625-9456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW-002275E
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: