Provider Demographics
NPI:1396116596
Name:LEE, DEREK (DPT)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2668 E CITIZENS DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4796
Mailing Address - Country:US
Mailing Address - Phone:479-442-7473
Mailing Address - Fax:844-809-1417
Practice Address - Street 1:2668 E CITIZENS DR STE 5
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4796
Practice Address - Country:US
Practice Address - Phone:479-442-7473
Practice Address - Fax:479-239-5444
Is Sole Proprietor?:No
Enumeration Date:2015-10-13
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT 3374225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARPENDINGMedicaid