Provider Demographics
NPI:1417629197
Name:COLPAERT, DEREK (PTA)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:COLPAERT
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33900 HARPER AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-350-2644
Mailing Address - Fax:
Practice Address - Street 1:580 N TELEGRAPH RD UNIT B
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-3337
Practice Address - Country:US
Practice Address - Phone:734-430-8330
Practice Address - Fax:734-430-8331
Is Sole Proprietor?:No
Enumeration Date:2021-10-01
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5502003910225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant