Provider Demographics
NPI:1427309228
Name:DEROSA, NICOLE M (PSYD, BCBA-D, LBA)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:M
Last Name:DEROSA
Suffix:
Gender:F
Credentials:PSYD, BCBA-D, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 INTREPID LN STE 2
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13205-2546
Mailing Address - Country:US
Mailing Address - Phone:315-797-6241
Mailing Address - Fax:
Practice Address - Street 1:100 INTREPID LN STE 2
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13205-2546
Practice Address - Country:US
Practice Address - Phone:315-797-6241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-20
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1107150103K00000X
NY020499103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst