Provider Demographics
NPI:1548600562
Name:DEROSIA, COURTNEY (MS)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:DEROSIA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:
Other - Last Name:DEROSIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9310 SIERRA AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-5711
Mailing Address - Country:US
Mailing Address - Phone:866-205-3595
Mailing Address - Fax:
Practice Address - Street 1:9310 SIERRA AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-5711
Practice Address - Country:US
Practice Address - Phone:866-205-3595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-05
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87985106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist