Provider Demographics
NPI:1609138262
Name:DEROUEN, KRISTEN DANIELLE (MOT)
Entity Type:Individual
Prefix:MISS
First Name:KRISTEN
Middle Name:DANIELLE
Last Name:DEROUEN
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:274 GOLDEN LAKE LOOP
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-5855
Mailing Address - Country:US
Mailing Address - Phone:225-278-3628
Mailing Address - Fax:
Practice Address - Street 1:161 MARINE STREET
Practice Address - Street 2:SUITE A
Practice Address - City:ST. AUGUSTINE
Practice Address - State:N/A
Practice Address - Zip Code:32084
Practice Address - Country:UM
Practice Address - Phone:225-278-3628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15224225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist