Provider Demographics
NPI:1134497548
Name:DERR, EDWARD RAY (LPC, NCC)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:RAY
Last Name:DERR
Suffix:
Gender:M
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:926 S DEVONSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-2721
Mailing Address - Country:US
Mailing Address - Phone:417-848-1849
Mailing Address - Fax:
Practice Address - Street 1:926 S DEVONSHIRE DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-2721
Practice Address - Country:US
Practice Address - Phone:417-848-1849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005040692101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional