Provider Demographics
NPI:1093775447
Name:DERRICK, ANGELA M (DPT)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:M
Last Name:DERRICK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MISS
Other - First Name:ANGELA
Other - Middle Name:M
Other - Last Name:SCHROEDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:402 MINARD ST
Mailing Address - Street 2:
Mailing Address - City:JERSEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62052-2630
Mailing Address - Country:US
Mailing Address - Phone:575-312-4439
Mailing Address - Fax:
Practice Address - Street 1:800 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:IL
Practice Address - Zip Code:62016-1436
Practice Address - Country:US
Practice Address - Phone:217-942-6946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM2654225100000X
IL070018073225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist