Healthcare Provider Details

I. General information

NPI: 1962165142
Provider Name (Legal Business Name): DERICK ALEXANDER MORALES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2021
Last Update Date: 10/14/2021
Certification Date: 10/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30837 E THOUSAND OAKS BLVD
WESTLAKE VILLAGE CA
91362-4039
US

IV. Provider business mailing address

14844 VALLEY VISTA BLVD
SHERMAN OAKS CA
91403-4116
US

V. Phone/Fax

Practice location:
  • Phone: 818-879-2091
  • Fax:
Mailing address:
  • Phone: 818-927-8102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number51481
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: