Provider Demographics
NPI:1316205594
Name:DERBAS, MARK JOHN (LPC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JOHN
Last Name:DERBAS
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 1:8503 75TH ST.
Mailing Address - Street 2:SUITE A
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-7620
Mailing Address - Country:US
Mailing Address - Phone:262-654-9370
Mailing Address - Fax:262-654-9379
Practice Address - Street 1:8503 75TH ST.
Practice Address - Street 2:SUITE A
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-7620
Practice Address - Country:US
Practice Address - Phone:262-654-9370
Practice Address - Fax:262-654-9379
Is Sole Proprietor?:No
Enumeration Date:2012-04-25
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1347-226101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor