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General NPI Number Information
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NPI Number | 1437423563
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Entity Type | Organization
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Legal Business Name | DEROSE FAMILY COUNSELING, LLC.
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Dates
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Enumeration Date | 03/07/2012
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Last Update Date | 03/07/2012
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Provider Practice Location Address
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Address Line | 316 5TH ST SUITE 1
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City | RACINE
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State | WI
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Zip | 53403-4606
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Country | US
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Telephone | 262-633-1235
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Fax | 262-633-1236
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Provider Business Mailing Address
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Address Line | 316 5TH ST SUITE 1
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City | RACINE
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State | WI
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Zip | 53403-4606
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Country | US
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Telephone | 262-633-1235
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Fax | 262-633-1236
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Authorized Official
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Title or Position | CERTIFIED PSYCHOTHERAPIST
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Name | TALIA DEROSE
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Credential | PHD
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Telephone | 262-633-1235
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 2958
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License Number State | WI
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