Provider Demographics
NPI:1184012379
Name:DEROIN, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:DEROIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SERENITY LN
Mailing Address - Street 2:
Mailing Address - City:COBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97408-9350
Mailing Address - Country:US
Mailing Address - Phone:541-687-1110
Mailing Address - Fax:
Practice Address - Street 1:1 SERENITY LN
Practice Address - Street 2:
Practice Address - City:COBURG
Practice Address - State:OR
Practice Address - Zip Code:97408-9350
Practice Address - Country:US
Practice Address - Phone:541-687-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-23
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YA0400X
OR06-03-62101YA0400X
OR22-QMHP-R-1561101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health