Provider Demographics
NPI:1316520547
Name:BROTHERTON, DEREK (PTA)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:BROTHERTON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 MARVIN LN
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:ME
Mailing Address - Zip Code:04348-3555
Mailing Address - Country:US
Mailing Address - Phone:207-215-4521
Mailing Address - Fax:
Practice Address - Street 1:105 MECHANIC ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:ME
Practice Address - Zip Code:04843-1811
Practice Address - Country:US
Practice Address - Phone:207-236-4197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-05
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant