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General NPI Number Information
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NPI Number | 1902579998
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Entity Type | Individual
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Provider Name | BRAD DEROMA
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Gender | Male
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Dates
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Enumeration Date | 07/27/2021
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Last Update Date | 10/23/2024
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Provider Practice Location Address
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Address Line | 15815 S LAKEWOOD PKWY W APT 2016
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City | PHOENIX
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State | AZ
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Zip | 85048-7291
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Country | US
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Telephone | 760-613-6861
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Fax |
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Provider Business Mailing Address
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Address Line | 15815 S LAKEWOOD PKWY W APT 2119
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City | PHOENIX
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State | AZ
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Zip | 85048-7294
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Country | US
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Telephone | 760-613-6861
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | LIAC-155343
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License Number State | AZ
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