Provider Demographics
NPI:1871741645
Name:DERDERIAN, LAURA (CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:LAURA
Middle Name:
Last Name:DERDERIAN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 NW 12TH AVE
Mailing Address - Street 2:DEBBIE SCHOOL- DEPT. OF PEDIATRICS-UNIV OF MIAMI
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1005
Mailing Address - Country:US
Mailing Address - Phone:305-243-6221
Mailing Address - Fax:
Practice Address - Street 1:1601 NW 12TH AVE
Practice Address - Street 2:DEBBIE SCHOOL- DEPT. OF PEDIATRICS-UNIV OF MIAMI
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:305-243-6221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 7735235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL889928200Medicaid