Provider Demographics
NPI:1093312811
Name:GILBERT, DERRICK (CRADC)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:GILBERT
Suffix:
Gender:M
Credentials:CRADC
Other - Prefix:
Other - First Name:DERRICK
Other - Middle Name:
Other - Last Name:GILBERT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRADC
Mailing Address - Street 1:104 CASTLE LN
Mailing Address - Street 2:
Mailing Address - City:HIGHLANDVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65669-8096
Mailing Address - Country:US
Mailing Address - Phone:417-838-6818
Mailing Address - Fax:
Practice Address - Street 1:895 STATE HIGHWAY 248 STE C
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-4013
Practice Address - Country:US
Practice Address - Phone:417-544-8394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-05
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1364101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty