Provider Demographics
NPI:1619248572
Name:DERRICOTT, LAURA R (PT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:R
Last Name:DERRICOTT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:R
Other - Last Name:WINTERBERGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:104 MACDUFF RD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19711-1514
Mailing Address - Country:US
Mailing Address - Phone:585-613-5257
Mailing Address - Fax:
Practice Address - Street 1:104 MACDUFF RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19711-1514
Practice Address - Country:US
Practice Address - Phone:585-613-5257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-24
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23799225100000X
DEJ1-0004020225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP01059773OtherMEDICARE RAILROAD
MD234318ZBL8Medicare PIN