Provider Demographics
NPI:1912405242
Name:DEREK H ELDER LPC PLLC
Entity Type:Organization
Organization Name:DEREK H ELDER LPC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:HARTLEY
Authorized Official - Last Name:ELDER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:210-326-4663
Mailing Address - Street 1:16607 BLANCO RD STE 502
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-1910
Mailing Address - Country:US
Mailing Address - Phone:210-326-4663
Mailing Address - Fax:210-428-6454
Practice Address - Street 1:16607 BLANCO RD STE 502
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-1910
Practice Address - Country:US
Practice Address - Phone:210-326-4663
Practice Address - Fax:210-428-6454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-01
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63638261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX281324801Medicaid