Provider Demographics
NPI:1104047778
Name:DERDERIAN, VICKY L (LPTA)
Entity type:Individual
Prefix:MRS
First Name:VICKY
Middle Name:L
Last Name:DERDERIAN
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3923 HICKORY VIEW DR.
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45011
Mailing Address - Country:US
Mailing Address - Phone:513-895-3229
Mailing Address - Fax:
Practice Address - Street 1:855 STAHLHEBER RD
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45013-1963
Practice Address - Country:US
Practice Address - Phone:513-844-8004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA-1103225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant