Provider Demographics
NPI:1073173498
Name:KAUFMAN, DERRICK LEIGH JR (LICDC)
Entity Type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:LEIGH
Last Name:KAUFMAN
Suffix:JR
Gender:M
Credentials:LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 ORCHARD PL
Mailing Address - Street 2:
Mailing Address - City:WINTERSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43953-3942
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4977 NORTHCUTT PL
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-3839
Practice Address - Country:US
Practice Address - Phone:937-387-6395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC162158101YA0400X
OH171475171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1073173498Medicaid