Provider Demographics
NPI:1548525900
Name:DETRICK, LINDA (MOTR/L)
Entity type:Individual
Prefix:MS
First Name:LINDA
Middle Name:
Last Name:DETRICK
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 FOREST EDGE CT
Mailing Address - Street 2:
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-9599
Mailing Address - Country:US
Mailing Address - Phone:724-935-1178
Mailing Address - Fax:
Practice Address - Street 1:3390 SAXONBURG BLVD STE 250
Practice Address - Street 2:
Practice Address - City:GLENSHAW
Practice Address - State:PA
Practice Address - Zip Code:15116-3160
Practice Address - Country:US
Practice Address - Phone:412-767-5967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG005220225700000X
PAOC011976225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist