Provider Demographics
NPI:1013888072
Name:ROSEAU, DERTHLEY
Entity type:Individual
Prefix:
First Name:DERTHLEY
Middle Name:
Last Name:ROSEAU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 LENOX ST UNIT 211
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02062-3694
Mailing Address - Country:US
Mailing Address - Phone:774-360-4266
Mailing Address - Fax:
Practice Address - Street 1:165 LENOX ST UNIT 211
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:MA
Practice Address - Zip Code:02062-3694
Practice Address - Country:US
Practice Address - Phone:774-360-4266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-15
Last Update Date:2025-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA550E6BEF-6F0B-4BE8-B101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health