Provider Demographics
NPI:1750014379
Name:OWEN, DEREK GALLEGOS
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:GALLEGOS
Last Name:OWEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1629 S 980 EAST CIR
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-2260
Mailing Address - Country:US
Mailing Address - Phone:435-705-9574
Mailing Address - Fax:
Practice Address - Street 1:121 W TABERNACLE ST
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-3338
Practice Address - Country:US
Practice Address - Phone:435-673-3553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-01
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11409078-4201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist