Healthcare Provider Details

I. General information

NPI: 1982527834
Provider Name (Legal Business Name): DEREENA KUTTOOKARAN PAULOSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 E VINE ST
LODI CA
95240-3148
US

IV. Provider business mailing address

1701 S MILLS AVE APT 66
LODI CA
95242-4260
US

V. Phone/Fax

Practice location:
  • Phone: 909-396-8900
  • Fax: 909-396-8900
Mailing address:
  • Phone: 909-396-8900
  • Fax: 909-396-8900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number32105
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: