Provider Demographics
NPI:1013408517
Name:WHITE, DERRICK A (DPT)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:A
Last Name:WHITE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 5TH AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703-1290
Mailing Address - Country:US
Mailing Address - Phone:304-525-4445
Mailing Address - Fax:304-529-7449
Practice Address - Street 1:2240 5TH AVE STE 101
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25703-1290
Practice Address - Country:US
Practice Address - Phone:304-525-4445
Practice Address - Fax:304-529-7449
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV003968225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist