Provider Demographics
NPI:1740879410
Name:SHAIN, DERRICK (PSYCHOTHERAPIST)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:SHAIN
Suffix:
Gender:M
Credentials:PSYCHOTHERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 GRANDVIEW MDWS DR UNIT F205
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-8966
Mailing Address - Country:US
Mailing Address - Phone:660-383-2641
Mailing Address - Fax:
Practice Address - Street 1:1650 38TH ST STE 100E
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-2624
Practice Address - Country:US
Practice Address - Phone:660-383-2641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health