Provider Demographics
NPI:1699218776
Name:DERDERIAN, OKSANA
Entity Type:Individual
Prefix:
First Name:OKSANA
Middle Name:
Last Name:DERDERIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35800 BOB HOPE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-1739
Mailing Address - Country:US
Mailing Address - Phone:191-754-7676
Mailing Address - Fax:
Practice Address - Street 1:35800 BOB HOPE DR STE 200
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-1739
Practice Address - Country:US
Practice Address - Phone:917-547-6767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-22
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25978235Z00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty