Provider Demographics
NPI:1770035594
Name:RAYNES, DEREK (MS, ATC, PES, CFCE)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:RAYNES
Suffix:
Gender:M
Credentials:MS, ATC, PES, CFCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5510 MACCORKLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-2320
Mailing Address - Country:US
Mailing Address - Phone:304-720-5433
Mailing Address - Fax:
Practice Address - Street 1:5510 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-2320
Practice Address - Country:US
Practice Address - Phone:304-720-5433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAT0013062255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer