Provider Demographics
NPI:1396828125
Name:DERUYTER, JOHN (PSY D)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:DERUYTER
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 73511
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99707-3511
Mailing Address - Country:US
Mailing Address - Phone:907-451-8208
Mailing Address - Fax:907-451-8207
Practice Address - Street 1:530 7TH AVE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4971
Practice Address - Country:US
Practice Address - Phone:907-451-8208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK547103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily