Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant | 285318 | OR |
NPI | 1023431848 |
---|---|
Provider Name | Derrick Bailey |
First Address | Portland, OR 97221-1043 |
Second Address | Portland, OR 97221-1043 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/01/2014 |
Last Update Date | 30/01/2014 |