Provider Demographics
NPI:1275992117
Name:OVER, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:OVER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 SUSSEX DR
Mailing Address - Street 2:
Mailing Address - City:CARLISLE
Mailing Address - State:PA
Mailing Address - Zip Code:17013-4800
Mailing Address - Country:US
Mailing Address - Phone:717-386-9328
Mailing Address - Fax:
Practice Address - Street 1:1 LONGSDORF WAY
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:PA
Practice Address - Zip Code:17015-7623
Practice Address - Country:US
Practice Address - Phone:717-245-9941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-21
Last Update Date:2016-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI002990225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant