Provider Demographics
NPI:1962165142
Name:MORALES, DERICK ALEXANDER
Entity type:Individual
Prefix:
First Name:DERICK
Middle Name:ALEXANDER
Last Name:MORALES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14844 VALLEY VISTA BLVD
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-4116
Mailing Address - Country:US
Mailing Address - Phone:818-927-8102
Mailing Address - Fax:
Practice Address - Street 1:30837 E THOUSAND OAKS BLVD
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91362-4039
Practice Address - Country:US
Practice Address - Phone:818-879-2091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51481225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant