Provider Demographics
NPI:1376121905
Name:MCCLOUD, DERRICKA
Entity Type:Individual
Prefix:
First Name:DERRICKA
Middle Name:
Last Name:MCCLOUD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 SW 12TH AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33069-3593
Mailing Address - Country:US
Mailing Address - Phone:954-933-3407
Mailing Address - Fax:
Practice Address - Street 1:555 SW 12TH AVE STE 107
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33069-3593
Practice Address - Country:US
Practice Address - Phone:954-933-3407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-02
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health