Provider Demographics
NPI:1679040901
Name:SAMPSON, DERRICK LOREN (MS, SUDT, MHP)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:LOREN
Last Name:SAMPSON
Suffix:
Gender:M
Credentials:MS, SUDT, MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 112TH ST E
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98446-5307
Mailing Address - Country:US
Mailing Address - Phone:253-536-6425
Mailing Address - Fax:
Practice Address - Street 1:12201 PACIFIC AVE S
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98444-5126
Practice Address - Country:US
Practice Address - Phone:253-536-6425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60749434101YA0400X
WACG60832062101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health