Healthcare Provider Details

I. General information

NPI: 1861699639
Provider Name (Legal Business Name): BRET SHERIDAN DERRICK PT, DPT, OCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 04/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E BROADWAY STE 340
COLUMBIA MO
65203-4208
US

IV. Provider business mailing address

111 E BROADWAY STE 340
COLUMBIA MO
65203-4208
US

V. Phone/Fax

Practice location:
  • Phone: 573-808-2392
  • Fax: 888-738-3034
Mailing address:
  • Phone: 573-808-2392
  • Fax: 888-738-3034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251E1200X
TaxonomyErgonomics Physical Therapist
License Number01248
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number01248
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: