Provider Demographics
NPI:1710202130
Name:CHI, DERICK KUMBA (BA)
Entity Type:Individual
Prefix:
First Name:DERICK
Middle Name:KUMBA
Last Name:CHI
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8901 N OLIE AVE
Mailing Address - Street 2:APT 4
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114-2540
Mailing Address - Country:US
Mailing Address - Phone:240-565-8223
Mailing Address - Fax:405-528-1802
Practice Address - Street 1:27777 INKSTER RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-5326
Practice Address - Country:US
Practice Address - Phone:248-436-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-29
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101Y00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101Y00000XBehavioral Health & Social Service ProvidersCounselor