Provider Demographics
NPI:1679611420
Name:DERBY, KENNETH MARK (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MARK
Last Name:DERBY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1124 E 35TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99203-3168
Mailing Address - Country:US
Mailing Address - Phone:509-747-7460
Mailing Address - Fax:509-323-5965
Practice Address - Street 1:1124 E 35TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99203-3168
Practice Address - Country:US
Practice Address - Phone:509-747-7460
Practice Address - Fax:509-323-5965
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2204103TB0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical