Provider Demographics
NPI:1376153874
Name:BOYD, DERRICK (PTA, BS)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:BOYD
Suffix:
Gender:M
Credentials:PTA, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1978 OBERLIN DR APT 1978
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-2868
Mailing Address - Country:US
Mailing Address - Phone:618-292-7886
Mailing Address - Fax:
Practice Address - Street 1:1373 DADRIAN PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-1767
Practice Address - Country:US
Practice Address - Phone:706-261-8467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-09
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.008973225200000X
MO2020030538225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant