Provider Demographics
NPI:1124253547
Name:DERITA, DAVID JAMES (PHD)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:JAMES
Last Name:DERITA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 W LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:TOWER LAKES
Mailing Address - State:IL
Mailing Address - Zip Code:60010-1130
Mailing Address - Country:US
Mailing Address - Phone:847-526-6557
Mailing Address - Fax:
Practice Address - Street 1:215 W LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:TOWER LAKES
Practice Address - State:IL
Practice Address - Zip Code:60010-1130
Practice Address - Country:US
Practice Address - Phone:847-526-6557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-29
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-002434103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical