Provider Demographics
NPI:1144999012
Name:DERBIS, MADELEINE GRACE
Entity type:Individual
Prefix:
First Name:MADELEINE
Middle Name:GRACE
Last Name:DERBIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10753 23RD ST NE
Mailing Address - Street 2:
Mailing Address - City:SAINT MICHAEL
Mailing Address - State:MN
Mailing Address - Zip Code:55376-7502
Mailing Address - Country:US
Mailing Address - Phone:763-614-7021
Mailing Address - Fax:
Practice Address - Street 1:16500 W 78TH ST # B
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55346-4302
Practice Address - Country:US
Practice Address - Phone:763-614-7021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-13
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer