Provider Demographics
NPI:1225496888
Name:HARDY, DERICK JEROME (MASTERS)
Entity Type:Individual
Prefix:MR
First Name:DERICK
Middle Name:JEROME
Last Name:HARDY
Suffix:
Gender:M
Credentials:MASTERS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6027 CANDICE LN
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70615-4773
Mailing Address - Country:US
Mailing Address - Phone:337-404-1721
Mailing Address - Fax:337-434-2333
Practice Address - Street 1:1202 KIRKMAN ST STE A
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-5391
Practice Address - Country:US
Practice Address - Phone:337-419-3586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-10
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1889253Medicaid