Provider Demographics
NPI:1659582153
Name:DERN, DARRELL JAMES (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:JAMES
Last Name:DERN
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16036 N 11TH AVE UNIT 1112
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-8207
Mailing Address - Country:US
Mailing Address - Phone:602-315-4171
Mailing Address - Fax:
Practice Address - Street 1:16036 N 11TH AVE UNIT 1112
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023-8207
Practice Address - Country:US
Practice Address - Phone:602-315-4171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0250235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist