Provider Demographics
NPI:1780158444
Name:FUQUA, DERRELL ANTHONY SR (CDCA)
Entity type:Individual
Prefix:
First Name:DERRELL
Middle Name:ANTHONY
Last Name:FUQUA
Suffix:SR
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2529 BRIDGEPORT DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-1433
Mailing Address - Country:US
Mailing Address - Phone:937-278-0869
Mailing Address - Fax:
Practice Address - Street 1:2529 BRIDGEPORT DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-1433
Practice Address - Country:US
Practice Address - Phone:937-278-0869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH169214101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)