Healthcare Provider Details

I. General information

NPI: 1689767741
Provider Name (Legal Business Name): ANYA GENIESER-DEROSA PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 GRAVEL PIKE UNIT B
RED HILL PA
18076-1428
US

IV. Provider business mailing address

1848 CANDLEWYCK LN
GREEN LANE PA
18054-2047
US

V. Phone/Fax

Practice location:
  • Phone: 484-624-2415
  • Fax: 215-679-2875
Mailing address:
  • Phone: 484-624-2415
  • Fax: 215-679-2875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS015501
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS015501
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: