Provider Demographics
NPI:1306254271
Name:DEROIN, MIA BETH (DO)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:BETH
Last Name:DEROIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 W OAKDALE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-6419
Mailing Address - Country:US
Mailing Address - Phone:773-871-5926
Mailing Address - Fax:
Practice Address - Street 1:4412 N OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:HARWOOD HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60706-4836
Practice Address - Country:US
Practice Address - Phone:630-673-9499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-23
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist