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NPI Code Detail

MEDICARE: MS. MITHSOU DERODEL

MEDICARE: MS. MITHSOU DERODEL
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YM0800XMental Health Counselor
2101200000XDrama Therapist

General Provider Information

NPI Number : 1366288250
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. MITHSOU DERODEL
Provider Business Mailing Address
First Line : 23318 130TH AVE
Second Line :
City : ROSEDALE
State : NY
Zip : 11422-1102
Country : US
Telephone Number : 347-479-7905
Fax Number :
Provider Business Practice Location Address
First Line : 23318 130TH AVE
Second Line :
City : ROSEDALE
State : NY
Zip : 11422-1102
Country : US
Telephone Number : 347-479-7905
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/01/2024
Last Update Date : 07/01/2024

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