Healthcare Provider Details

I. General information

NPI: 1922652189
Provider Name (Legal Business Name): DIANE DEROSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2019
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N MISSOURI ST STE A
WEST MEMPHIS AR
72301-3148
US

IV. Provider business mailing address

1304 BRENTWOOD DR
WEST MEMPHIS AR
72301-1884
US

V. Phone/Fax

Practice location:
  • Phone: 870-733-5963
  • Fax:
Mailing address:
  • Phone: 870-514-7918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: