Provider Demographics
NPI:1013595776
Name:GREEN, DERIK (MSW, QMHP-T)
Entity Type:Individual
Prefix:MR
First Name:DERIK
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:MSW, QMHP-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:291 INDEPENDENCE BLVD STE 532
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-5473
Mailing Address - Country:US
Mailing Address - Phone:757-962-6889
Mailing Address - Fax:
Practice Address - Street 1:291 INDEPENDENCE BLVD STE 532
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-5473
Practice Address - Country:US
Practice Address - Phone:757-962-6889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0734002974101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty