Provider Demographics
NPI:1932676525
Name:CHAVIS, DERECK FITZGERALD
Entity Type:Individual
Prefix:
First Name:DERECK
Middle Name:FITZGERALD
Last Name:CHAVIS
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 1:521 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-1376
Mailing Address - Country:US
Mailing Address - Phone:616-866-6859
Mailing Address - Fax:
Practice Address - Street 1:521 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-1376
Practice Address - Country:US
Practice Address - Phone:616-866-6859
Practice Address - Fax:616-866-6897
Is Sole Proprietor?:No
Enumeration Date:2018-11-01
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201010344225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist