Provider Demographics
NPI:1932621323
Name:DEREMO, CARLY ANNE (PSYD)
Entity type:Individual
Prefix:DR
First Name:CARLY
Middle Name:ANNE
Last Name:DEREMO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10552 SUCCESS LN STE E
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45458-3664
Mailing Address - Country:US
Mailing Address - Phone:937-815-7208
Mailing Address - Fax:855-251-5211
Practice Address - Street 1:10552 SUCCESS LN STE E
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45458-3664
Practice Address - Country:US
Practice Address - Phone:937-815-7208
Practice Address - Fax:855-251-5211
Is Sole Proprietor?:No
Enumeration Date:2017-07-07
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH08398103TC0700X, 103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program