Provider Demographics
NPI:1821642406
Name:DERUS, CONNIE J
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:J
Last Name:DERUS
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:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:ACME
Mailing Address - State:WA
Mailing Address - Zip Code:98220-0098
Mailing Address - Country:US
Mailing Address - Phone:206-251-4776
Mailing Address - Fax:
Practice Address - Street 1:5133 TURKINGTON RD
Practice Address - Street 2:
Practice Address - City:ACME
Practice Address - State:WA
Practice Address - Zip Code:98220-9638
Practice Address - Country:US
Practice Address - Phone:206-251-4776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60303063101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional