Provider Demographics
NPI:1346968047
Name:DERR, JAMES DAVID III (LHMCA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:DAVID
Last Name:DERR
Suffix:III
Gender:M
Credentials:LHMCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3135 364TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:FALL CITY
Mailing Address - State:WA
Mailing Address - Zip Code:98024-9428
Mailing Address - Country:US
Mailing Address - Phone:832-287-5124
Mailing Address - Fax:
Practice Address - Street 1:9575 ETHAN WADE WAY SE
Practice Address - Street 2:
Practice Address - City:SNOQUALMIE
Practice Address - State:WA
Practice Address - Zip Code:98065-9577
Practice Address - Country:US
Practice Address - Phone:425-831-5425
Practice Address - Fax:425-831-5428
Is Sole Proprietor?:No
Enumeration Date:2022-08-18
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61267077101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2228264Medicaid