Provider Demographics
NPI:1972266401
Name:YEAGER, DERRICK THOMAS (LAPC)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:THOMAS
Last Name:YEAGER
Suffix:
Gender:M
Credentials:LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 S 31ST ST STE 201
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-3593
Mailing Address - Country:US
Mailing Address - Phone:701-780-6821
Mailing Address - Fax:701-780-1973
Practice Address - Street 1:3535 S 31ST ST STE 201
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-3593
Practice Address - Country:US
Practice Address - Phone:701-780-6821
Practice Address - Fax:701-780-1973
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1102-1-1-21A101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor