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General NPI Number Information
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NPI Number | 1053416560
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Entity Type | Individual
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Provider Name | MICHELLE MARIE DERKOVITZ RPT
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Gender | Female
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Dates
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Enumeration Date | 09/13/2006
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Last Update Date | 02/03/2012
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Provider Practice Location Address
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Address Line | 346 DELAWARE AVENUE
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City | BUFFALO
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State | NY
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Zip | 14202
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Country | US
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Telephone | 716-856-7500
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Fax |
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Provider Business Mailing Address
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Address Line | 6 GRACE WAY
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City | LANCASTER
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State | NY
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Zip | 14086-2347
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Country | US
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Telephone | 716-651-0149
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 017335-1
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License Number State | NY
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