Healthcare Provider Details

I. General information

NPI: 1982199360
Provider Name (Legal Business Name): DANIELLE DARLENE DERETCHIN ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2018
Last Update Date: 07/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1508 N THORNTON AVE STE 106
DALTON GA
30720
US

IV. Provider business mailing address

6397 LEE HWY STE 300
CHATTANOOGA TN
37421-2564
US

V. Phone/Fax

Practice location:
  • Phone: 706-226-0816
  • Fax: 706-226-9584
Mailing address:
  • Phone: 423-238-7217
  • Fax: 423-362-8684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT003421
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: