Provider Demographics
NPI:1619174729
Name:EDLIN, DEREK THOMAS (COTA)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:THOMAS
Last Name:EDLIN
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 MADISON AVENUE
Mailing Address - Street 2:
Mailing Address - City:BRANDENBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40108
Mailing Address - Country:US
Mailing Address - Phone:270-828-8059
Mailing Address - Fax:
Practice Address - Street 1:814 OLD EKRON RD
Practice Address - Street 2:
Practice Address - City:BRANDENBURG
Practice Address - State:KY
Practice Address - Zip Code:40108-1149
Practice Address - Country:US
Practice Address - Phone:270-422-2148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA3750224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant