Provider Demographics
NPI:1619187127
Name:DERRY, ELIZABETH ANN
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:DERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 803
Mailing Address - Street 2:
Mailing Address - City:SUNSET BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90742-0803
Mailing Address - Country:US
Mailing Address - Phone:562-592-3214
Mailing Address - Fax:
Practice Address - Street 1:16521 23RD STREET
Practice Address - Street 2:
Practice Address - City:SUNSET BEACH
Practice Address - State:CA
Practice Address - Zip Code:90742
Practice Address - Country:US
Practice Address - Phone:562-592-3214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5044225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand