Provider Demographics
NPI:1447768056
Name:DERKS, SAMONE L (LMSW)
Entity Type:Individual
Prefix:
First Name:SAMONE
Middle Name:L
Last Name:DERKS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 W BARAGA AVE STE F
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-4761
Mailing Address - Country:US
Mailing Address - Phone:906-361-1386
Mailing Address - Fax:906-273-1650
Practice Address - Street 1:129 W BARAGA AVE STE F
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-4761
Practice Address - Country:US
Practice Address - Phone:906-361-1386
Practice Address - Fax:906-273-1650
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-17
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW607819701041C0700X
MI68011020881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical