Provider Demographics
NPI:1063775476
Name:DEROUCHIE, KIMBERLY ANNE
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNE
Last Name:DEROUCHIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANNE
Other - Last Name:FOX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:180 SWIFT RD
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-5723
Mailing Address - Country:US
Mailing Address - Phone:607-687-8610
Mailing Address - Fax:607-223-7005
Practice Address - Street 1:1062 RT. 38
Practice Address - Street 2:
Practice Address - City:OWEGO
Practice Address - State:NY
Practice Address - Zip Code:13827
Practice Address - Country:US
Practice Address - Phone:607-687-8610
Practice Address - Fax:607-223-7005
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency