Provider Demographics
NPI:1700367000
Name:DERENICK, HEATHER NICOLE (DPT)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:NICOLE
Last Name:DERENICK
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 1:4750 LINDLE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17111-2428
Mailing Address - Country:US
Mailing Address - Phone:717-803-3342
Mailing Address - Fax:717-974-8743
Practice Address - Street 1:488 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRING GROVE
Practice Address - State:PA
Practice Address - Zip Code:17362-1122
Practice Address - Country:US
Practice Address - Phone:717-690-0107
Practice Address - Fax:717-974-8743
Is Sole Proprietor?:No
Enumeration Date:2018-08-24
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT027106225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist