Provider Demographics
NPI:1629412630
Name:DELLER, DORA (MS, CCC)
Entity Type:Individual
Prefix:
First Name:DORA
Middle Name:
Last Name:DELLER
Suffix:
Gender:F
Credentials:MS, CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54109 SUNDERLAND DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-1970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5601 HATCHERY RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329-3451
Practice Address - Country:US
Practice Address - Phone:248-674-9292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-21
Last Update Date:2013-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101000855235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7101000855OtherSTATE OF MICHIGAN DEPT OF LICENSING AND REGULATORY AFFAIRS