=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356801344
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEREK JOSEPH DRASBA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2019
-----------------------------------------------------
Last Update Date | 03/25/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 423 SCRANTON CARBONDALE HWY
-----------------------------------------------------
City | SCRANTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18508-1115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-207-5502
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 743 CLEVIO ST
-----------------------------------------------------
City | OLD FORGE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18518-2232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-650-5005
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OC016060
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------