Provider Demographics
NPI:1487013116
Name:ANGEL DERUVO PLLC
Entity Type:Organization
Organization Name:ANGEL DERUVO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DERUVO
Authorized Official - Suffix:
Authorized Official - Credentials:SLP
Authorized Official - Phone:917-273-1448
Mailing Address - Street 1:47 CEDAR TER
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-1701
Mailing Address - Country:US
Mailing Address - Phone:917-273-1448
Mailing Address - Fax:718-442-7641
Practice Address - Street 1:47 CEDAR TER
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-1701
Practice Address - Country:US
Practice Address - Phone:917-273-1448
Practice Address - Fax:718-442-7641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-23
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8751388235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty