Provider Demographics
NPI:1811591290
Name:DERREVERE, MARK TERRENCE
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:TERRENCE
Last Name:DERREVERE
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:LONE TREE MEDICAL CENTER
Mailing Address - Street 2:9548 PARK MEADOWS DRIVE
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124
Mailing Address - Country:US
Mailing Address - Phone:720-281-8114
Mailing Address - Fax:720-553-0901
Practice Address - Street 1:LONE TREE MEDICAL CENTER
Practice Address - Street 2:9548 PARK MEADOWS DRIVE
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124
Practice Address - Country:US
Practice Address - Phone:720-281-8114
Practice Address - Fax:720-553-0901
Is Sole Proprietor?:No
Enumeration Date:2020-11-25
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOT.0001549225XH1200X, 225X00000X
225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand