Provider Demographics
NPI:1033373782
Name:REDDICKS, DEREK LEROY
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:LEROY
Last Name:REDDICKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 S PROCTOR ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-2047
Mailing Address - Country:US
Mailing Address - Phone:253-396-5930
Mailing Address - Fax:253-566-2252
Practice Address - Street 1:815 S PEARL ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98465-2117
Practice Address - Country:US
Practice Address - Phone:253-396-5937
Practice Address - Fax:253-566-2252
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-11
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health