Provider Demographics
NPI:1093234528
Name:DERRICK, EMILY LOUISE (MA)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:LOUISE
Last Name:DERRICK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 N MADRID AVE
Mailing Address - Street 2:
Mailing Address - City:NEWBURY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91320-3315
Mailing Address - Country:US
Mailing Address - Phone:415-819-1305
Mailing Address - Fax:
Practice Address - Street 1:260 MAPLE CT STE 125
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-3519
Practice Address - Country:US
Practice Address - Phone:180-524-3808
Practice Address - Fax:805-243-8085
Is Sole Proprietor?:No
Enumeration Date:2017-09-15
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA88471106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist