Provider Demographics
NPI:1013036607
Name:DEROCHE, THEODORE R (PHD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:R
Last Name:DEROCHE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 NORTH CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:FLAGLER BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32136
Mailing Address - Country:US
Mailing Address - Phone:386-439-1403
Mailing Address - Fax:386-439-1403
Practice Address - Street 1:2760 SE 17TH STREET
Practice Address - Street 2:SUITE 300
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471
Practice Address - Country:US
Practice Address - Phone:352-629-4113
Practice Address - Fax:386-439-1403
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH50101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health