Provider Demographics
NPI:1275060790
Name:DERADO, REBECCA GRACE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:GRACE
Last Name:DERADO
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:DERADO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:14926 RIVERDALE DR E APT 16
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46033-1628
Mailing Address - Country:US
Mailing Address - Phone:317-750-4232
Mailing Address - Fax:
Practice Address - Street 1:15515 STONY CREEK WAY
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-4386
Practice Address - Country:US
Practice Address - Phone:317-776-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-15
Last Update Date:2017-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22006439A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist