Provider Demographics
NPI:1619299369
Name:DAVIS, DEREK R
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:R
Last Name:DAVIS
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 1:604 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19801-1424
Mailing Address - Country:US
Mailing Address - Phone:302-737-4100
Mailing Address - Fax:302-655-5030
Practice Address - Street 1:604 W 10TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19801-1424
Practice Address - Country:US
Practice Address - Phone:302-737-4100
Practice Address - Fax:302-655-5030
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-23
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE123126101YA0400X
PAPC002803101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional