Provider Demographics
NPI:1366820839
Name:WOODBURY, DERRICK LAMONT (LPC)
Entity Type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:LAMONT
Last Name:WOODBURY
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 1:5928 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74112-2913
Mailing Address - Country:US
Mailing Address - Phone:918-970-0028
Mailing Address - Fax:918-960-7308
Practice Address - Street 1:10212 E 41ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-3703
Practice Address - Country:US
Practice Address - Phone:918-970-0028
Practice Address - Fax:918-960-7308
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-15
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5604101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional