Provider Demographics
NPI:1760710693
Name:DEROUIN, ANGELA RAE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:RAE
Last Name:DEROUIN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:RAE
Other - Last Name:SAWALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:200 N PATRICK BLVD STE 250
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-5883
Mailing Address - Country:US
Mailing Address - Phone:888-754-0398
Mailing Address - Fax:
Practice Address - Street 1:200 N PATRICK BLVD STE 250
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-5883
Practice Address - Country:US
Practice Address - Phone:262-255-1180
Practice Address - Fax:262-255-1638
Is Sole Proprietor?:No
Enumeration Date:2009-12-04
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3231-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100007790Medicaid