Provider Demographics
NPI:1932763083
Name:DEROSIA, HEATHER (MSSW)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:DEROSIA
Suffix:
Gender:F
Credentials:MSSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4539 N 22ND ST STE R
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4639
Mailing Address - Country:US
Mailing Address - Phone:615-924-9205
Mailing Address - Fax:
Practice Address - Street 1:1626 N LITCHFIELD RD STE 200
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-1254
Practice Address - Country:US
Practice Address - Phone:615-924-9205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-24
Last Update Date:2025-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
AZLMSW-210341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL330000014Medicaid