Provider Demographics
NPI:1972756039
Name:DERRIS, SANDY J (CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:SANDY
Middle Name:J
Last Name:DERRIS
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 OTTOWA RD S
Mailing Address - Street 2:
Mailing Address - City:MARLBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:07746-1246
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:88 OTTOWA RD S
Practice Address - Street 2:
Practice Address - City:MARLBORO
Practice Address - State:NJ
Practice Address - Zip Code:07746-1246
Practice Address - Country:US
Practice Address - Phone:732-617-9142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-02
Last Update Date:2008-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001325-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist