Provider Demographics
NPI:1811334451
Name:DERRICK, THOMAS
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:DERRICK
Suffix:
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 1:3301 CIVIC CENTER DR APT 8D
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-8150
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3301 CIVIC CENTER DR APT 8D
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-8150
Practice Address - Country:US
Practice Address - Phone:818-383-6718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-22
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst