Basic Information
| Provider Information | |||||||||
| NPI: | 1932650736 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DERRICKSON | ||||||||
| FirstName: | BRANDT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 N OAKLAND AVE | ||||||||
| Address2: | |||||||||
| City: | BOLIVAR | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656133011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173266000 | ||||||||
| FaxNumber: | 4173286338 | ||||||||
| Practice Location | |||||||||
| Address1: | 1155 W PARKVIEW ST STE 2D | ||||||||
| Address2: | |||||||||
| City: | BOLIVAR | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656137800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177772663 | ||||||||
| FaxNumber: | 4173262666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2016 | ||||||||
| LastUpdateDate: | 10/18/2016 | ||||||||
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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 | 2255A2300X | 2016004534 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.