Healthcare Provider Details

I. General information

NPI: 1700367000
Provider Name (Legal Business Name): HEATHER NICOLE DERENICK DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2018
Last Update Date: 08/27/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

488 N MAIN ST
SPRING GROVE PA
17362-1122
US

IV. Provider business mailing address

4750 LINDLE RD STE 100
HARRISBURG PA
17111-2428
US

V. Phone/Fax

Practice location:
  • Phone: 717-690-0107
  • Fax: 717-974-8743
Mailing address:
  • Phone: 717-803-3342
  • Fax: 717-974-8743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT027106
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: