Provider Demographics
NPI:1417368564
Name:GABRESKI, DEREK WILLIAM
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:WILLIAM
Last Name:GABRESKI
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 1:1243 S 136TH ST
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98168-2861
Mailing Address - Country:US
Mailing Address - Phone:814-688-8613
Mailing Address - Fax:
Practice Address - Street 1:1243 S 136TH ST
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98168-2861
Practice Address - Country:US
Practice Address - Phone:814-688-8613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-12
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60442641225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist