Provider Demographics
NPI:1568914125
Name:BRASCH, DEREK W (LMT)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:W
Last Name:BRASCH
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 CORDOVA ST STE 105
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99501-3783
Mailing Address - Country:US
Mailing Address - Phone:907-277-5525
Mailing Address - Fax:907-277-5526
Practice Address - Street 1:626 CORDOVA ST STE 105
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99501-3783
Practice Address - Country:US
Practice Address - Phone:907-277-5525
Practice Address - Fax:907-277-5526
Is Sole Proprietor?:No
Enumeration Date:2016-10-31
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK111032225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist