Provider Demographics
NPI:1356399166
Name:DEROME, CLIFTON JAMES
Entity type:Individual
Prefix:MR
First Name:CLIFTON
Middle Name:JAMES
Last Name:DEROME
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 1:1267 W DEER HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:IN
Mailing Address - Zip Code:47371-8381
Mailing Address - Country:US
Mailing Address - Phone:260-726-7394
Mailing Address - Fax:260-726-2941
Practice Address - Street 1:1267 W DEER HAVEN DR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:IN
Practice Address - Zip Code:47371-8381
Practice Address - Country:US
Practice Address - Phone:260-726-7394
Practice Address - Fax:260-726-2941
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22003469A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist