Provider Demographics
NPI:1740417351
Name:DERRICK, AMANDA BETH (MSOT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:BETH
Last Name:DERRICK
Suffix:
Gender:F
Credentials:MSOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 E MOYER RD
Mailing Address - Street 2:
Mailing Address - City:POTTSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19464-1202
Mailing Address - Country:US
Mailing Address - Phone:610-323-2781
Mailing Address - Fax:
Practice Address - Street 1:3075 RIDGE PIKE
Practice Address - Street 2:
Practice Address - City:EAGLEVILLE
Practice Address - State:PA
Practice Address - Zip Code:19403-1538
Practice Address - Country:US
Practice Address - Phone:215-361-1906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-22
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC011149225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics