Provider Demographics
NPI:1831421668
Name:DERUCKI, CAROL A (LMHC)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:DERUCKI
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46528-7000
Mailing Address - Country:US
Mailing Address - Phone:574-533-1234
Mailing Address - Fax:574-537-2652
Practice Address - Street 1:330 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46528-7000
Practice Address - Country:US
Practice Address - Phone:574-537-2652
Practice Address - Fax:574-537-2652
Is Sole Proprietor?:No
Enumeration Date:2010-02-04
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
IN39002267A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor