Provider Demographics
NPI:1154885101
Name:DESROSIERS, CHRISTA
Entity type:Individual
Prefix:
First Name:CHRISTA
Middle Name:
Last Name:DESROSIERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1684 SE 23RD LN
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33035-1251
Mailing Address - Country:US
Mailing Address - Phone:786-738-1011
Mailing Address - Fax:
Practice Address - Street 1:3180 BISCAYNE BLVD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33137-4127
Practice Address - Country:US
Practice Address - Phone:786-738-1011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW208081041C0700X
FL15885104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical