Provider Demographics
NPI:1811339294
Name:EIDSON, DERICK ALLEN
Entity type:Individual
Prefix:
First Name:DERICK
Middle Name:ALLEN
Last Name:EIDSON
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 1:19108 COUNTY ROAD 3560
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-0177
Mailing Address - Country:US
Mailing Address - Phone:580-421-1800
Mailing Address - Fax:
Practice Address - Street 1:19108 COUNTY ROAD 3560
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-0177
Practice Address - Country:US
Practice Address - Phone:580-421-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-25
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health