Provider Demographics
NPI:1295169381
Name:DERUS, DAVID R (PSYD, LPC-IT)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:DERUS
Suffix:
Gender:M
Credentials:PSYD, LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3398 E MARIA DR
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481-1362
Mailing Address - Country:US
Mailing Address - Phone:715-341-7441
Mailing Address - Fax:
Practice Address - Street 1:3398 E MARIA DR
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-1362
Practice Address - Country:US
Practice Address - Phone:715-341-7441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-26
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1857101YP2500X
WI3817103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional