Provider Demographics
NPI:1437920519
Name:DEROO, MADYSON LOUSIE
Entity Type:Individual
Prefix:
First Name:MADYSON
Middle Name:LOUSIE
Last Name:DEROO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4157 S VANDECAR RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-9555
Mailing Address - Country:US
Mailing Address - Phone:616-283-8595
Mailing Address - Fax:
Practice Address - Street 1:602 BEECH ST STE 2100
Practice Address - Street 2:
Practice Address - City:CLARE
Practice Address - State:MI
Practice Address - Zip Code:48617-1477
Practice Address - Country:US
Practice Address - Phone:989-802-5131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7152000772235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist