MEDICARE: ALYSSA DERBY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XP0200X	Pediatric Occupational Therapist
2	225X00000X	Occupational Therapist	OTP-OT-LIC-10655	MT

General Provider Information

NPI Number	:	1538944012
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALYSSA DERBY

Provider Business Mailing Address
First Line	:	3759 CROSSCLIFFE PATH
Second Line	:
City	:	ROSEMOUNT
State	:	MN
Zip	:	55068-6173
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2683 PALMER ST STE B
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59808-1757
Country	:	US
Telephone Number	:	406-214-3131
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2023
Last Update Date	:	02/23/2024

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Directions to “ ALYSSA DERBY ” Practice Location

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