Provider Demographics
NPI:1356503387
Name:LITTLE, DEREK BENTLEY (DPT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:BENTLEY
Last Name:LITTLE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:1350 UPPER HEMBREE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-0928
Practice Address - Country:US
Practice Address - Phone:770-771-6751
Practice Address - Fax:770-754-9820
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT9339225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA611I650232Medicare PIN
GA511I650205Medicare PIN