Provider Demographics
NPI:1588249676
Name:DEROSE MARRIAGE AND FAMILY THERAPY CORPORATION
Entity type:Organization
Organization Name:DEROSE MARRIAGE AND FAMILY THERAPY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:LORRAINE
Authorized Official - Last Name:DEROSE
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:805-242-1375
Mailing Address - Street 1:1026 PALM ST STE 215
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-3260
Mailing Address - Country:US
Mailing Address - Phone:805-242-1375
Mailing Address - Fax:
Practice Address - Street 1:1026 PALM ST STE 215
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-3260
Practice Address - Country:US
Practice Address - Phone:805-242-1375
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)