Healthcare Provider Details

I. General information

NPI: 1467413864
Provider Name (Legal Business Name): ANN S DERISO MSW LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 08/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

938 PENN ST
READING PA
19602
US

IV. Provider business mailing address

200 NORTH 7TH ST
LEBANON PA
17046
US

V. Phone/Fax

Practice location:
  • Phone: 610-478-8088
  • Fax: 610-478-8176
Mailing address:
  • Phone: 717-273-1710
  • Fax: 717-273-1416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberSW125062
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSW125062
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW-015993
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: