Provider Demographics
NPI:1619440104
Name:ESTRADA, DERECK DAVID (LPMHC)
Entity Type:Individual
Prefix:
First Name:DERECK
Middle Name:DAVID
Last Name:ESTRADA
Suffix:
Gender:M
Credentials:LPMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:639 SHADOW WAY
Mailing Address - Street 2:
Mailing Address - City:CENTRAL POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97502-2526
Mailing Address - Country:US
Mailing Address - Phone:541-414-7383
Mailing Address - Fax:
Practice Address - Street 1:8495 CRATER LAKE HWY # 116B
Practice Address - Street 2:
Practice Address - City:WHITE CITY
Practice Address - State:OR
Practice Address - Zip Code:97503-3011
Practice Address - Country:US
Practice Address - Phone:541-826-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC4199101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health