Provider Demographics
NPI:1114018447
Name:DEPERRY, RAENA SUE (AUD)
Entity Type:Individual
Prefix:DR
First Name:RAENA
Middle Name:SUE
Last Name:DEPERRY
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1119 STATE ST APT 164
Mailing Address - Street 2:
Mailing Address - City:RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54022-3403
Mailing Address - Country:US
Mailing Address - Phone:715-426-0223
Mailing Address - Fax:
Practice Address - Street 1:401 STAGELINE RD
Practice Address - Street 2:STE. 6
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-7897
Practice Address - Country:US
Practice Address - Phone:715-531-6710
Practice Address - Fax:715-531-6711
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FM8072231H00000X
WI515-156231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN849410000OtherMHCP