Provider Demographics
NPI:1871841577
Name:CARUSO, DEREK S (MSW, MSN, PMHNP-BC)
Entity type:Individual
Prefix:MR
First Name:DEREK
Middle Name:S
Last Name:CARUSO
Suffix:
Gender:M
Credentials:MSW, MSN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 WILLIAMS BLVD APT 1D
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-2413
Mailing Address - Country:US
Mailing Address - Phone:631-747-8121
Mailing Address - Fax:
Practice Address - Street 1:16 WILLIAMS BLVD APT 1D
Practice Address - Street 2:
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-2413
Practice Address - Country:US
Practice Address - Phone:631-747-8121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY086771104100000X
NY0840671041C0700X
NY744382163WP0808X
NYF405069363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1184445835OtherTYPE 2 NPI - ORGANIZATION
NY03482717Medicaid
NY13545756OtherCAQH ID #
NY13545756OtherCAQH ID #
NY621330OtherNAICS CODE
NY144307507OtherNYBE BUSINESS ID