Provider Demographics
NPI:1215365663
Name:STRUCHTEMEYER, DEREK (LPC)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:STRUCHTEMEYER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 PAPER TRAIL WAY STE 106
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-5204
Mailing Address - Country:US
Mailing Address - Phone:678-880-4645
Mailing Address - Fax:
Practice Address - Street 1:310 PAPER TRAIL WAY STE 106
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-5204
Practice Address - Country:US
Practice Address - Phone:678-880-4645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-23
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002981101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional