Provider Demographics
NPI:1649706417
Name:DERRICK, WILLIAM JR
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:DERRICK
Suffix:JR
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 1:3085 E FLAMINGO RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-4308
Mailing Address - Country:US
Mailing Address - Phone:702-868-5580
Mailing Address - Fax:
Practice Address - Street 1:3085 E FLAMINGO RD
Practice Address - Street 2:SUITE B
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-4308
Practice Address - Country:US
Practice Address - Phone:702-868-5580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health