Provider Demographics
NPI:1992049795
Name:DEROUEN, MICHELE ELIZABETH (BSPTA)
Entity type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:ELIZABETH
Last Name:DEROUEN
Suffix:
Gender:F
Credentials:BSPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 UTAH AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-5932
Mailing Address - Country:US
Mailing Address - Phone:575-491-1500
Mailing Address - Fax:
Practice Address - Street 1:27 CALLE DE SUENOS
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-9501
Practice Address - Country:US
Practice Address - Phone:575-491-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-16
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM106S00000X
NMA-0719225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant