Provider Demographics
NPI:1851857510
Name:FORSYTHE, DERRICK (LPC)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:FORSYTHE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 APPLEROCK DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-3855
Mailing Address - Country:US
Mailing Address - Phone:660-676-7526
Mailing Address - Fax:
Practice Address - Street 1:1428 N STATE HIGHWAY 47
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:MO
Practice Address - Zip Code:63383-1375
Practice Address - Country:US
Practice Address - Phone:660-676-7526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-18
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018040870101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional