Provider Demographics
NPI:1528341062
Name:DERKIN, MARIJO LOUISE (MA CCC/SPL)
Entity type:Individual
Prefix:MRS
First Name:MARIJO
Middle Name:LOUISE
Last Name:DERKIN
Suffix:
Gender:F
Credentials:MA CCC/SPL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4758 FAR HILLS RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-1024
Mailing Address - Country:US
Mailing Address - Phone:419-882-4880
Mailing Address - Fax:
Practice Address - Street 1:5950 AIRPORT HWY
Practice Address - Street 2:SUITE 17
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-7382
Practice Address - Country:US
Practice Address - Phone:419-865-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2046235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist