Provider Demographics
NPI:1922503036
Name:SHERIDAN, DEREK LARRY
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:LARRY
Last Name:SHERIDAN
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 1:28 E SANBORN AVE
Mailing Address - Street 2:
Mailing Address - City:CROSWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48422-1319
Mailing Address - Country:US
Mailing Address - Phone:810-300-6801
Mailing Address - Fax:
Practice Address - Street 1:1300 BEARD ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-6562
Practice Address - Country:US
Practice Address - Phone:810-982-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009391225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist