Provider Demographics
NPI:1619531084
Name:CUMBERLAND, DEREK (LMT,MMP)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:CUMBERLAND
Suffix:
Gender:M
Credentials:LMT,MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 OAKLEIGH PL
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-6297
Mailing Address - Country:US
Mailing Address - Phone:601-941-6970
Mailing Address - Fax:
Practice Address - Street 1:505 OAKLEIGH PL
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-6297
Practice Address - Country:US
Practice Address - Phone:601-941-6970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-30
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1133225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist