Provider Demographics
NPI:1851874564
Name:FARMER, DERICK NELSON
Entity Type:Individual
Prefix:
First Name:DERICK
Middle Name:NELSON
Last Name:FARMER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10228 KESSLER ST APT A
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66212-5357
Mailing Address - Country:US
Mailing Address - Phone:620-288-0768
Mailing Address - Fax:
Practice Address - Street 1:300 W 19TH TER
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-2026
Practice Address - Country:US
Practice Address - Phone:816-404-5709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-09
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS47261041C0700X
MO20180017141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490074453Medicaid