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General NPI Number Information
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NPI Number | 1265650667
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Entity Type | Individual
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Provider Name | ELIZABETH MORROW DEROSE MD
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Gender | Female
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Dates
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Enumeration Date | 04/23/2007
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Last Update Date | 09/28/2023
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Provider Practice Location Address
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Address Line | 300 68TH ST SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49548-6927
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Country | US
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Telephone | 616-281-6372
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Fax | 616-281-6459
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Provider Business Mailing Address
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Address Line | 360 GRAND RIVER DR NE
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City | ADA
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State | MI
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Zip | 49301-9597
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Country | US
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Telephone | 248-563-9508
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0804X
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Taxonomy Name | Child & Adolescent Psychiatry Physician
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License Number | 4301106410
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 2084P0804X
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Taxonomy Name | Child & Adolescent Psychiatry Physician
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License Number | 01070813A
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License Number State | IN
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Taxonomy #3
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 4301106410
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License Number State | MI
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