MEDICARE: DR. MIRIAM S. DERISO PHD

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
1	103T00000X	Psychologist	PS007137L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659371201
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MIRIAM S. DERISO PHD

Provider Business Mailing Address
First Line	:	321 S LANG AVE
Second Line	:
City	:	PITTSBURGH
State	:	PA
Zip	:	15208-2749
Country	:	US
Telephone Number	:	412-371-8899
Fax Number	:

Provider Business Practice Location Address
First Line	:	321 S LANG AVE
Second Line	:
City	:	PITTSBURGH
State	:	PA
Zip	:	15208-2749
Country	:	US
Telephone Number	:	412-371-8899
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2005
Last Update Date	:	07/18/2016

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