Provider Demographics
NPI:1841910619
Name:COLUCCI, DEREK (MS, LBS)
Entity type:Individual
Prefix:MR
First Name:DEREK
Middle Name:
Last Name:COLUCCI
Suffix:
Gender:M
Credentials:MS, LBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOCK HAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:17745-1122
Mailing Address - Country:US
Mailing Address - Phone:570-295-4924
Mailing Address - Fax:
Practice Address - Street 1:1990 W 3RD ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-7808
Practice Address - Country:US
Practice Address - Phone:570-320-2816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH005968103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst