Provider Demographics
NPI:1669200333
Name:DERKSON, MICHELLE (CERTIFICATE)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:DERKSON
Suffix:
Gender:F
Credentials:CERTIFICATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 MATTHEWS DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45215-1836
Mailing Address - Country:US
Mailing Address - Phone:859-802-1069
Mailing Address - Fax:
Practice Address - Street 1:817 MATTHEWS DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45215-1836
Practice Address - Country:US
Practice Address - Phone:859-802-1069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-24
Last Update Date:2025-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities