Provider Demographics
NPI:1679742910
Name:MORRISON, DEIDRA CANTRELL (DPT)
Entity type:Individual
Prefix:
First Name:DEIDRA
Middle Name:CANTRELL
Last Name:MORRISON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12030 SILVERLAKE PARK DR
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-9480
Mailing Address - Country:US
Mailing Address - Phone:804-931-6864
Mailing Address - Fax:240-483-4175
Practice Address - Street 1:6965 PIAZZA GRANDE AVE #210
Practice Address - Street 2:210-4
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835
Practice Address - Country:US
Practice Address - Phone:804-931-6864
Practice Address - Fax:240-483-4175
Is Sole Proprietor?:No
Enumeration Date:2008-02-20
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT31472225100000X
WVPT.003024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810025110Medicaid
OH0089767Medicaid
WVQ42525AMedicare PIN