Provider Demographics
NPI:1821743303
Name:HENDERSHOT, DEREK JOSEPH (DPT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:JOSEPH
Last Name:HENDERSHOT
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 BETTINO DR
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:07439-1003
Mailing Address - Country:US
Mailing Address - Phone:973-222-2439
Mailing Address - Fax:
Practice Address - Street 1:7 BETTINO DR
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NJ
Practice Address - Zip Code:07439-1003
Practice Address - Country:US
Practice Address - Phone:973-222-2439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-14
Last Update Date:2023-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA02072000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist