Individual
MARY DERAEDT
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
610 MAIN ST, LAFAYETTE, IN 47901-1451
(765) 423-2638
Mailing address
610 MAIN ST, LAFAYETTE, IN 47901-1451
(765) 423-2638
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
39001884A
IN
Other
Enumeration date
09/06/2007
Last updated
09/10/2007
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