Provider Demographics
NPI:1922518885
Name:DERHEIM, JEREMY (MA OTR/L)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:DERHEIM
Suffix:
Gender:M
Credentials:MA OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14130 COTTONWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:BECKER
Mailing Address - State:MN
Mailing Address - Zip Code:55308
Mailing Address - Country:US
Mailing Address - Phone:320-267-3660
Mailing Address - Fax:
Practice Address - Street 1:2829 VERNDALE AVE
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303
Practice Address - Country:US
Practice Address - Phone:763-231-2590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-05
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105473225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist