Provider Demographics
NPI:1982932141
Name:DEREU, SHELLEY (LCSW)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:DEREU
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4161 TAMIAMI TRL
Mailing Address - Street 2:SUITE 401
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-9204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:941-623-1215
Practice Address - Street 1:4161 TAMIAMI TRL
Practice Address - Street 2:SUITE 401
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-9204
Practice Address - Country:US
Practice Address - Phone:239-980-4156
Practice Address - Fax:941-623-1215
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-30
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 73111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical