Provider Demographics
NPI:1639408214
Name:WALL, DEREK JUSTIN (MS, LPC, NCC)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:JUSTIN
Last Name:WALL
Suffix:
Gender:M
Credentials:MS, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13211 WINDYGATE LN
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-2227
Mailing Address - Country:US
Mailing Address - Phone:314-607-2801
Mailing Address - Fax:
Practice Address - Street 1:12400 OLIVE BLVD
Practice Address - Street 2:SUITE 205
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-5454
Practice Address - Country:US
Practice Address - Phone:314-607-2801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-10
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009035484101YP2500X
IL180.007223101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional