Provider Demographics
NPI:1689130395
Name:DERLETH, OLIVIA
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:DERLETH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 MAYBROOK RD STE K
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL HALL
Mailing Address - State:NY
Mailing Address - Zip Code:10916-2741
Mailing Address - Country:US
Mailing Address - Phone:845-636-4344
Mailing Address - Fax:845-636-4355
Practice Address - Street 1:2531 ROUTE 52 STE 2
Practice Address - Street 2:
Practice Address - City:HOPEWELL JUNCTION
Practice Address - State:NY
Practice Address - Zip Code:12533-3227
Practice Address - Country:US
Practice Address - Phone:845-592-4747
Practice Address - Fax:845-592-4749
Is Sole Proprietor?:No
Enumeration Date:2019-02-18
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0404361225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist