Provider Demographics
NPI:1134552722
Name:BAYERSDORFER, DERICK NATHANIEL (COTA)
Entity type:Individual
Prefix:
First Name:DERICK
Middle Name:NATHANIEL
Last Name:BAYERSDORFER
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3216 SPARGER RD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-1651
Mailing Address - Country:US
Mailing Address - Phone:954-696-4808
Mailing Address - Fax:
Practice Address - Street 1:864 US HWY 158 BUSINESS WEST
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:NC
Practice Address - Zip Code:27589
Practice Address - Country:US
Practice Address - Phone:252-257-2011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8813224Z00000X
FL12319224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant