Provider Demographics
NPI:1326092339
Name:OVERLY, DEREK C (MS PT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:C
Last Name:OVERLY
Suffix:
Gender:M
Credentials:MS PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 396
Mailing Address - Street 2:
Mailing Address - City:GUNNISON
Mailing Address - State:UT
Mailing Address - Zip Code:84634-0396
Mailing Address - Country:US
Mailing Address - Phone:435-528-7575
Mailing Address - Fax:435-528-7000
Practice Address - Street 1:13 EAST CENTER
Practice Address - Street 2:
Practice Address - City:GUNNISON
Practice Address - State:UT
Practice Address - Zip Code:84634-0396
Practice Address - Country:US
Practice Address - Phone:435-528-7575
Practice Address - Fax:435-528-7000
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT313309-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870554446OV1OtherEMIA
UT46973OtherPEHP
UT6400177OtherUHC
UT107008847101OtherIHC
UT577666OtherDMBA