Basic Information
| Provider Information | |||||||||
| NPI: | 1922518885 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DERHEIM | ||||||||
| FirstName: | JEREMY | ||||||||
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| Credential: | MA OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14130 COTTONWOOD BLVD | ||||||||
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| City: | BECKER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202673660 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2829 VERNDALE AVE | ||||||||
| Address2: | |||||||||
| City: | ANOKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632312590 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2017 | ||||||||
| LastUpdateDate: | 10/05/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 105473 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.