Provider Demographics
NPI:1417212564
Name:DEREKA, NATALIE D (DPT)
Entity type:Individual
Prefix:DR
First Name:NATALIE
Middle Name:D
Last Name:DEREKA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 SHAFFER ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1656
Mailing Address - Country:US
Mailing Address - Phone:269-384-3066
Mailing Address - Fax:269-384-3065
Practice Address - Street 1:1820 SHAFFER ST
Practice Address - Street 2:SUITE B
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1656
Practice Address - Country:US
Practice Address - Phone:269-384-3066
Practice Address - Fax:269-384-3065
Is Sole Proprietor?:No
Enumeration Date:2012-07-05
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015948225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist