Healthcare Provider Details

I. General information

NPI: 1255259958
Provider Name (Legal Business Name): KRISTIN MARIE DERRICKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 YOUNG WAY
RICHMOND HILL GA
31324-7238
US

IV. Provider business mailing address

888 YOUNG WAY
RICHMOND HILL GA
31324-7238
US

V. Phone/Fax

Practice location:
  • Phone: 254-654-0141
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT008736
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: