Healthcare Provider Details

I. General information

NPI: 1093775447
Provider Name (Legal Business Name): ANGELA M DERRICK DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANGELA M SCHROEDER MPT

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 08/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 SCHOOL ST
CARROLLTON IL
62016-1436
US

IV. Provider business mailing address

402 MINARD ST
JERSEYVILLE IL
62052-2630
US

V. Phone/Fax

Practice location:
  • Phone: 217-942-6946
  • Fax:
Mailing address:
  • Phone: 575-312-4439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberNM2654
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070018073
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: