Provider Demographics
NPI:1114609245
Name:PROVENCHER, DEREK MARC (PT, DPT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:MARC
Last Name:PROVENCHER
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9309 PERSIMMON BROOK TRL APT 215
Mailing Address - Street 2:
Mailing Address - City:THONOTOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:33592-3963
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16037B TAMPA PALMS BLVD W
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-2001
Practice Address - Country:US
Practice Address - Phone:813-542-8188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PTT40333225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist