Provider Demographics
NPI:1457657496
Name:WAUGH, DEREK JAMES
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:JAMES
Last Name:WAUGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 S RANKIN ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-5354
Mailing Address - Country:US
Mailing Address - Phone:405-464-6393
Mailing Address - Fax:
Practice Address - Street 1:10317 GREENBRIAR PL
Practice Address - Street 2:SUITE 200
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-7651
Practice Address - Country:US
Practice Address - Phone:405-464-6393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-09
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK103K00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst