Provider Demographics
NPI:1912939000
Name:PARIS, DEREK LOUIS (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:LOUIS
Last Name:PARIS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11307 NOTESTINE RD
Mailing Address - Street 2:
Mailing Address - City:GRABILL
Mailing Address - State:IN
Mailing Address - Zip Code:46741-9735
Mailing Address - Country:US
Mailing Address - Phone:260-627-0844
Mailing Address - Fax:
Practice Address - Street 1:11307 NOTESTINE RD
Practice Address - Street 2:
Practice Address - City:GRABILL
Practice Address - State:IN
Practice Address - Zip Code:46741-9735
Practice Address - Country:US
Practice Address - Phone:260-627-0844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN667720Medicare ID - Type Unspecified
INS01602Medicare UPIN