Provider Demographics
NPI:1992034672
Name:SKINNER, DERRICK SR (LCSW)
Entity Type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:
Last Name:SKINNER
Suffix:SR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USA MEDDAC
Mailing Address - Street 2:11050 MOUNT BELVEDERE BLVD
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602-5438
Mailing Address - Country:US
Mailing Address - Phone:315-772-3173
Mailing Address - Fax:
Practice Address - Street 1:12647 OLIVE BLVD
Practice Address - Street 2:STE 600
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6393
Practice Address - Country:US
Practice Address - Phone:800-325-3982
Practice Address - Fax:877-685-9880
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-09
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2406104100000X, 1041C0700X
NE10411041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical