Provider Demographics
NPI:1174135768
Name:BOTHWELL, DERICK DEANTE (DPT, ATC)
Entity type:Individual
Prefix:
First Name:DERICK
Middle Name:DEANTE
Last Name:BOTHWELL
Suffix:
Gender:M
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:464 SAINT LUKES DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-7104
Mailing Address - Country:US
Mailing Address - Phone:334-244-6699
Mailing Address - Fax:
Practice Address - Street 1:464 SAINT LUKES DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-7104
Practice Address - Country:US
Practice Address - Phone:334-244-6699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-1087225100000X
AL18392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer