Basic Information
| Provider Information | |||||||||
| NPI: | 1679911689 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PROUDFOOT | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | PHILIP | ||||||||
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| Credential: | LPTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2325 N LATHROP RD | ||||||||
| Address2: | |||||||||
| City: | SWANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435589675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193445054 | ||||||||
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| Practice Location | |||||||||
| Address1: | 339 E MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447202593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304988239 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2013 | ||||||||
| LastUpdateDate: | 06/12/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 08852 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.