Provider Demographics
NPI:1932961711
Name:DERRICK, KENYONNE
Entity Type:Individual
Prefix:MS
First Name:KENYONNE
Middle Name:
Last Name:DERRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KENYONNE
Other - Middle Name:
Other - Last Name:DERRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4009 EUFAULA AVE
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403-1132
Mailing Address - Country:US
Mailing Address - Phone:918-682-2841
Mailing Address - Fax:
Practice Address - Street 1:4009 EUFAULA AVE
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-1132
Practice Address - Country:US
Practice Address - Phone:918-682-2841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-26
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK103TC1900X, 171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171400000XOther Service ProvidersHealth & Wellness CoachGroup - Single Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling