Provider Demographics
NPI:1326349739
Name:SMITH, DERRICK EDWARD (COUNSELOR/THERAPIST)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:EDWARD
Last Name:SMITH
Suffix:
Gender:M
Credentials:COUNSELOR/THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11337 SW IRONWOOD LOOP
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-4200
Mailing Address - Country:US
Mailing Address - Phone:503-521-6146
Mailing Address - Fax:
Practice Address - Street 1:222 HOLIDAY DR
Practice Address - Street 2:
Practice Address - City:WHITE RIVER JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05001-2043
Practice Address - Country:US
Practice Address - Phone:802-295-2943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-16
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional