Provider Demographics
NPI:1366969917
Name:DERRICK, MILES COLISON (ATC)
Entity type:Individual
Prefix:MR
First Name:MILES
Middle Name:COLISON
Last Name:DERRICK
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 MOULTON ROAD
Mailing Address - Street 2:
Mailing Address - City:WAITSFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05673-7070
Mailing Address - Country:US
Mailing Address - Phone:802-496-6344
Mailing Address - Fax:802-496-6315
Practice Address - Street 1:271 MOULTON ROAD
Practice Address - Street 2:
Practice Address - City:WAITSFIELD
Practice Address - State:VT
Practice Address - Zip Code:05673-7070
Practice Address - Country:US
Practice Address - Phone:802-496-6344
Practice Address - Fax:802-496-6315
Is Sole Proprietor?:No
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT104.0131948225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist