Provider Demographics
NPI:1104176387
Name:DERUYTER, JODIE LYNN (MS, BA, BCBA)
Entity type:Individual
Prefix:
First Name:JODIE
Middle Name:LYNN
Last Name:DERUYTER
Suffix:
Gender:F
Credentials:MS, BA, BCBA
Other - Prefix:
Other - First Name:JODIE
Other - Middle Name:LYNN
Other - Last Name:WALDBAUER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1210 FOURIER DRIVE
Mailing Address - Street 2:SUITE #100
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-1969
Mailing Address - Country:US
Mailing Address - Phone:608-662-9327
Mailing Address - Fax:608-662-9041
Practice Address - Street 1:1210 FOURIER DR
Practice Address - Street 2:SUITE #100
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-1969
Practice Address - Country:US
Practice Address - Phone:608-662-9327
Practice Address - Fax:608-662-9041
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst