Provider Demographics
NPI:1558075077
Name:DERAMUS, MARCUS JAMES
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:JAMES
Last Name:DERAMUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 ABERCORN DR
Mailing Address - Street 2:
Mailing Address - City:DEATSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36022-5539
Mailing Address - Country:US
Mailing Address - Phone:334-538-9853
Mailing Address - Fax:
Practice Address - Street 1:131 MARKET PL
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-4900
Practice Address - Country:US
Practice Address - Phone:334-538-9853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL133N00000X, 171000000X, 221700000X, 225X00000X, 101YM0800X
171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No171000000XOther Service ProvidersMilitary Health Care ProviderGroup - Multi-Specialty
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist