Provider Demographics
NPI:1205134194
Name:DEROO, TARA LEE (LMSW)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:LEE
Last Name:DEROO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10569 N SPRINGFIELD CIR
Mailing Address - Street 2:
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464-1475
Mailing Address - Country:US
Mailing Address - Phone:616-772-6092
Mailing Address - Fax:
Practice Address - Street 1:10569 N SPRINGFIELD CIR
Practice Address - Street 2:
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-1475
Practice Address - Country:US
Practice Address - Phone:616-772-6092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010815841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical