Provider Demographics
NPI:1689161341
Name:PLACKER, DERIC THOMAS (MA)
Entity Type:Individual
Prefix:
First Name:DERIC
Middle Name:THOMAS
Last Name:PLACKER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43520 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93535-4089
Mailing Address - Country:US
Mailing Address - Phone:661-949-1206
Mailing Address - Fax:
Practice Address - Street 1:16940 CA-14
Practice Address - Street 2:
Practice Address - City:MOJAVE
Practice Address - State:CA
Practice Address - Zip Code:93501
Practice Address - Country:US
Practice Address - Phone:661-749-6087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-18
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA114766106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist