Provider Demographics
NPI:1528507027
Name:DERRICKSON, LAURA (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:DERRICKSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 W GOODALE ST
Mailing Address - Street 2:453
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-1597
Mailing Address - Country:US
Mailing Address - Phone:859-351-9316
Mailing Address - Fax:
Practice Address - Street 1:1545 HUY RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43224-3531
Practice Address - Country:US
Practice Address - Phone:614-365-5977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-16
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP. 12017235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist