MEDICARE: SEAN P DERRY LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	LPC10204	AZ

General Provider Information

NPI Number	:	1659353720
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SEAN P DERRY LPC

Provider Business Mailing Address
First Line	:	642 DAMERON DR
Second Line	:
City	:	PRESCOTT
State	:	AZ
Zip	:	86301-2411
Country	:	US
Telephone Number	:	928-445-5211
Fax Number	:	928-776-8484

Provider Business Practice Location Address
First Line	:	3345 N WINDSONG DR
Second Line	:	WINDSONG CLINIC
City	:	PRESCOTT VALLEY
State	:	AZ
Zip	:	86314-2283
Country	:	US
Telephone Number	:	928-445-5211
Fax Number	:	928-776-8484

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2005
Last Update Date	:	07/08/2007

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Directions to “ SEAN P DERRY LPC” Practice Location

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