Provider Demographics
NPI:1154973212
Name:DEREPENTIGNY, MADELINE MARY
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:MARY
Last Name:DEREPENTIGNY
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 1:2550 LAWLOR RD
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-6458
Mailing Address - Country:US
Mailing Address - Phone:907-455-4725
Mailing Address - Fax:
Practice Address - Street 1:2550 LAWLOR RD
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-6458
Practice Address - Country:US
Practice Address - Phone:907-455-4725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor