Provider Demographics
NPI:1740771260
Name:THOCKER, DEREK JAMES (MA, BCBA)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:JAMES
Last Name:THOCKER
Suffix:
Gender:M
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1428 44TH ST SW STE B
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-4312
Mailing Address - Country:US
Mailing Address - Phone:616-604-8492
Mailing Address - Fax:
Practice Address - Street 1:1428 44TH ST SW STE B
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-4312
Practice Address - Country:US
Practice Address - Phone:616-604-8492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1-18-32583103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst