Provider Demographics
NPI:1700100070
Name:DEROON-CASSINI, TERRI A (PHD)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:A
Last Name:DEROON-CASSINI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:TRAUMA AND CRITICAL CARE SURGERY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-8623
Mailing Address - Fax:414-805-8641
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:TRAUMA AND CRITICAL CARE SURGERY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-8623
Practice Address - Fax:414-805-8641
Is Sole Proprietor?:No
Enumeration Date:2010-03-16
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2860103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1700100070Medicaid
WI1700100070Medicaid