Provider Demographics
NPI:1972655967
Name:DERDEN, LAURA (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:DERDEN
Suffix:
Gender:F
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 1:500 TIGER BLVD
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-4208
Mailing Address - Country:US
Mailing Address - Phone:479-418-7300
Mailing Address - Fax:
Practice Address - Street 1:2740 COLLEGE AVENUE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-9310
Practice Address - Country:US
Practice Address - Phone:501-329-5459
Practice Address - Fax:501-325-1378
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP1699235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR141423721Medicaid