Provider Demographics
NPI:1215666045
Name:DEROSA, JOANNA
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:
Last Name:DEROSA
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 1:1137 EDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-6306
Mailing Address - Country:US
Mailing Address - Phone:407-720-6381
Mailing Address - Fax:
Practice Address - Street 1:1137 EDGEWATER DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-6306
Practice Address - Country:US
Practice Address - Phone:407-720-6381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-07
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225A00000X
FLMH23940101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist