Provider Demographics
NPI:1851811756
Name:DERUSHA, KILLIAN JAMES (LMSW)
Entity Type:Individual
Prefix:
First Name:KILLIAN
Middle Name:JAMES
Last Name:DERUSHA
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:SIERRA
Other - Middle Name:DESTINY
Other - Last Name:DERUSHA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1311 WAKARUSA DR STE 2100
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-4775
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:785-843-2219
Practice Address - Street 1:1311 WAKARUSA DR STE 2100
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-4775
Practice Address - Country:US
Practice Address - Phone:785-424-7770
Practice Address - Fax:785-843-2219
Is Sole Proprietor?:No
Enumeration Date:2017-06-21
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS10470104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS3004349890002Medicaid