Provider Demographics
NPI:1578761086
Name:DERITIS, COLLEEN ANN (MA, OTR/L, ACE CPT)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:ANN
Last Name:DERITIS
Suffix:
Gender:F
Credentials:MA, OTR/L, ACE CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 SMITH CIR
Mailing Address - Street 2:
Mailing Address - City:POINT PLEASANT
Mailing Address - State:NJ
Mailing Address - Zip Code:08742-5856
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:159 SMITH CIR
Practice Address - Street 2:
Practice Address - City:POINT PLEASANT BORO
Practice Address - State:NJ
Practice Address - Zip Code:08742-5414
Practice Address - Country:US
Practice Address - Phone:732-206-8189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-05
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005686225X00000X
NJ46TR00485500225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist