Provider Demographics
NPI:1437362415
Name:DERRICKSON, RICHARD ALLAN (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:ALLAN
Last Name:DERRICKSON
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 W 55TH ST
Mailing Address - Street 2:APT. 3A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-4503
Mailing Address - Country:US
Mailing Address - Phone:212-247-2745
Mailing Address - Fax:
Practice Address - Street 1:315 W 55TH ST
Practice Address - Street 2:APT. 3A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-4503
Practice Address - Country:US
Practice Address - Phone:212-247-2745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019749225100000X
NY004340225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist