Provider Demographics
NPI:1619104403
Name:THOMPSON, DEREK DEVAN (MA LMHC)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:DEVAN
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:MA LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19750 MINKLER RD
Mailing Address - Street 2:
Mailing Address - City:ADAMS CENTER
Mailing Address - State:NY
Mailing Address - Zip Code:13606-3122
Mailing Address - Country:US
Mailing Address - Phone:956-401-8650
Mailing Address - Fax:
Practice Address - Street 1:19750 MINKLER RD
Practice Address - Street 2:
Practice Address - City:ADAMS CENTER
Practice Address - State:NY
Practice Address - Zip Code:13606-3122
Practice Address - Country:US
Practice Address - Phone:956-401-8650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-18
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014190103TC1900X
NY007172101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling