Provider Demographics
NPI:1265883169
Name:SKAPARS, DEREK KRIST (LCDCI)
Entity type:Individual
Prefix:MR
First Name:DEREK
Middle Name:KRIST
Last Name:SKAPARS
Suffix:
Gender:M
Credentials:LCDCI
Other - Prefix:MR
Other - First Name:DEREK
Other - Middle Name:KRIST
Other - Last Name:SKAPARS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCDCI
Mailing Address - Street 1:2300 N MUSKINGUM AVE
Mailing Address - Street 2:B
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-1246
Mailing Address - Country:US
Mailing Address - Phone:602-768-8818
Mailing Address - Fax:877-729-4033
Practice Address - Street 1:1205 W UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79764-7119
Practice Address - Country:US
Practice Address - Phone:432-614-5720
Practice Address - Fax:877-729-4033
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-22
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24323101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)