Provider Demographics
NPI:1629473525
Name:FORRESTER, DEREK (MA, LPC)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:FORRESTER
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 TIMBERSTONE TRL
Mailing Address - Street 2:
Mailing Address - City:SIX MILE
Mailing Address - State:SC
Mailing Address - Zip Code:29682-4607
Mailing Address - Country:US
Mailing Address - Phone:864-356-5100
Mailing Address - Fax:
Practice Address - Street 1:103 TIMBERSTONE TRL
Practice Address - Street 2:
Practice Address - City:SIX MILE
Practice Address - State:SC
Practice Address - Zip Code:29682-4607
Practice Address - Country:US
Practice Address - Phone:864-356-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-04
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6459101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional