Provider Demographics
NPI:1225734148
Name:COLVIN, DERRION
Entity Type:Individual
Prefix:
First Name:DERRION
Middle Name:
Last Name:COLVIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 BROADMOOR DR APT F
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-3154
Mailing Address - Country:US
Mailing Address - Phone:314-368-3542
Mailing Address - Fax:
Practice Address - Street 1:280 BRIDGE ST STE 110
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-1759
Practice Address - Country:US
Practice Address - Phone:781-320-7646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health