Provider Demographics
NPI:1710270483
Name:DERMODY, ROBERTA JEANNE (DT)
Entity Type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:JEANNE
Last Name:DERMODY
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3917 WHITFIELD DR
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-1022
Mailing Address - Country:US
Mailing Address - Phone:618-235-1009
Mailing Address - Fax:
Practice Address - Street 1:3917 WHITFIELD DR
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-1022
Practice Address - Country:US
Practice Address - Phone:618-235-1009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-27
Last Update Date:2011-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist