Provider Demographics
NPI:1194830133
Name:BLANTON, DERRICK K (PYSD)
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:K
Last Name:BLANTON
Suffix:
Gender:M
Credentials:PYSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13284 BUGATTI DR
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-0916
Mailing Address - Country:US
Mailing Address - Phone:214-551-7104
Mailing Address - Fax:214-615-6358
Practice Address - Street 1:13284 BUGATTI DR
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-0916
Practice Address - Country:US
Practice Address - Phone:214-551-7104
Practice Address - Fax:214-615-6358
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32512103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX170206001Medicaid
TX170206001Medicaid
TX8F23177Medicare PIN
TX8F23279Medicare PIN
TX614153Medicare PIN
TX8F23280Medicare PIN