Provider Demographics
NPI:1801538814
Name:DERKS, ELYSIA FLORENCE
Entity type:Individual
Prefix:
First Name:ELYSIA
Middle Name:FLORENCE
Last Name:DERKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELYSIA
Other - Middle Name:FLORENCE
Other - Last Name:BOLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2101 WOODDALE DR STE A
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2933
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2925 BUCKLEY WAY
Practice Address - Street 2:
Practice Address - City:INVER GROVE HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55076-2018
Practice Address - Country:US
Practice Address - Phone:651-455-0561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-11
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106796225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist