Provider Demographics
NPI:1609165208
Name:DERAU, SANDRA L (MA)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:L
Last Name:DERAU
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 W HERMOSA DR
Mailing Address - Street 2:
Mailing Address - City:WICKENBURG
Mailing Address - State:AZ
Mailing Address - Zip Code:85390-1245
Mailing Address - Country:US
Mailing Address - Phone:928-671-0792
Mailing Address - Fax:928-684-1316
Practice Address - Street 1:730 W HERMOSA DR
Practice Address - Street 2:
Practice Address - City:WICKENBURG
Practice Address - State:AZ
Practice Address - Zip Code:85390-1245
Practice Address - Country:US
Practice Address - Phone:928-671-0792
Practice Address - Fax:928-684-1316
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-04
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-2145101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional