Provider Demographics
NPI:1922386572
Name:HINES, DERRICK BLAINE (DPT)
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:BLAINE
Last Name:HINES
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 1:139 ASHLAND CT
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-5373
Mailing Address - Country:US
Mailing Address - Phone:337-232-8721
Mailing Address - Fax:
Practice Address - Street 1:1144 COOLIDGE BLVD
Practice Address - Street 2:SUITE F
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2622
Practice Address - Country:US
Practice Address - Phone:337-232-8721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-01
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH6216225100000X
LA08100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA102I656395OtherMEDICARE PTAN