Provider Demographics
NPI:1679911689
Name:PROUDFOOT, DEREK PHILIP (LPTA)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:PHILIP
Last Name:PROUDFOOT
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2325 N LATHROP RD
Mailing Address - Street 2:
Mailing Address - City:SWANTON
Mailing Address - State:OH
Mailing Address - Zip Code:43558-9675
Mailing Address - Country:US
Mailing Address - Phone:419-344-5054
Mailing Address - Fax:
Practice Address - Street 1:339 E MAPLE ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-2593
Practice Address - Country:US
Practice Address - Phone:330-498-8239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH08852225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant