Provider Demographics
NPI:1881930758
Name:KISER, DERRICK C
Entity type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:C
Last Name:KISER
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 1:203 EAST ST
Mailing Address - Street 2:
Mailing Address - City:EASTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01027-1234
Mailing Address - Country:US
Mailing Address - Phone:774-823-5744
Mailing Address - Fax:
Practice Address - Street 1:203 EAST ST
Practice Address - Street 2:
Practice Address - City:EASTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01027-1234
Practice Address - Country:US
Practice Address - Phone:774-823-5744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-21
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101YP2500X, 101YS0200X
MAS564414182084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry