Provider Demographics
NPI:1922298991
Name:DERRY, JULIA L (LLP)
Entity Type:Individual
Prefix:MRS
First Name:JULIA
Middle Name:L
Last Name:DERRY
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:MRS
Other - First Name:JULIA
Other - Middle Name:L
Other - Last Name:MCKISSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LLP
Mailing Address - Street 1:1485 S M-139
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022
Mailing Address - Country:US
Mailing Address - Phone:269-925-0585
Mailing Address - Fax:269-927-1326
Practice Address - Street 1:1485 S M-139
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022
Practice Address - Country:US
Practice Address - Phone:269-925-0585
Practice Address - Fax:269-927-1326
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008191103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral