Healthcare Provider Details

I. General information

NPI: 1689593576
Provider Name (Legal Business Name): DEREK MICHAEL BECKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1356 N BRISTOL ST
SUN PRAIRIE WI
53590-1269
US

IV. Provider business mailing address

5119 BROOKFIELD PKWY APT 113
MADISON WI
53718-2129
US

V. Phone/Fax

Practice location:
  • Phone: 608-837-7600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number11784-146
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: