Healthcare Provider Details

I. General information

NPI: 1396828125
Provider Name (Legal Business Name): JOHN DERUYTER PSY. D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 ALASKA AVE.
WRANGELL AK
99929-2204
US

IV. Provider business mailing address

PO BOX 73511
FAIRBANKS AK
99707-3511
US

V. Phone/Fax

Practice location:
  • Phone: 907-388-4287
  • Fax:
Mailing address:
  • Phone: 907-451-8208
  • Fax: 907-451-8207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number547
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: