Provider Demographics
NPI:1831637503
Name:DRAPER, DERREK (LMT)
Entity Type:Individual
Prefix:
First Name:DERREK
Middle Name:
Last Name:DRAPER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 E ASHTON AVE
Mailing Address - Street 2:STE 207
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-4504
Mailing Address - Country:US
Mailing Address - Phone:801-604-5141
Mailing Address - Fax:
Practice Address - Street 1:1104 E ASHTON AVE
Practice Address - Street 2:STE 207
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-4504
Practice Address - Country:US
Practice Address - Phone:801-604-5141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-02
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7819372-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist