Provider Demographics
NPI:1518404557
Name:DERBY, CODY (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:DERBY
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 LAKELAND HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-2909
Mailing Address - Country:US
Mailing Address - Phone:863-413-4116
Mailing Address - Fax:
Practice Address - Street 1:2301 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-2909
Practice Address - Country:US
Practice Address - Phone:863-413-4116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-29
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20170023822255A2300X
FLAL51282255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer