Provider Demographics
NPI:1528449501
Name:DERENZO, JOHN (SLP)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:DERENZO
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8902 155TH AVE APT 2R
Mailing Address - Street 2:
Mailing Address - City:HOWARD BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11414-1501
Mailing Address - Country:US
Mailing Address - Phone:917-407-3789
Mailing Address - Fax:
Practice Address - Street 1:8902 155TH AVE APT 2R
Practice Address - Street 2:
Practice Address - City:HOWARD BEACH
Practice Address - State:NY
Practice Address - Zip Code:11414-1501
Practice Address - Country:US
Practice Address - Phone:917-407-3789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-15
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024569235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist