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General NPI Number Information
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NPI Number | 1700387495
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Entity Type | Individual
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Provider Name | DERICK HENRY ROLAND PT, DPT
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Gender | Male
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Dates
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Enumeration Date | 02/27/2018
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Last Update Date | 02/27/2018
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Provider Practice Location Address
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Address Line | 815 N CLARE AVE STE A
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City | HARRISON
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State | MI
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Zip | 48625-8177
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Country | US
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Telephone | 989-741-2205
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Fax |
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Provider Business Mailing Address
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Address Line | 3827 E HASKELL LAKE RD
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City | HARRISON
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State | MI
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Zip | 48625-8792
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Country | US
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Telephone |
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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 | 2251S0007X
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Taxonomy Name | Sports Physical Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2251X0800X
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Taxonomy Name | Orthopedic Physical Therapist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 5501016795
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License Number State | MI
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