Provider Demographics
NPI:1659831600
Name:YOUNG, DERICKA LEA (MS, LPC)
Entity type:Individual
Prefix:
First Name:DERICKA
Middle Name:LEA
Last Name:YOUNG
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:DERICKA
Other - Middle Name:LEA
Other - Last Name:KITTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:641 BAREBACK LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76131-3121
Mailing Address - Country:US
Mailing Address - Phone:682-258-9740
Mailing Address - Fax:
Practice Address - Street 1:641 BAREBACK LN
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76131-3121
Practice Address - Country:US
Practice Address - Phone:682-258-9740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-24
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX77911101YM0800X, 101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional