Healthcare Provider Details

I. General information

NPI: 1568938645
Provider Name (Legal Business Name): DANIELLE PAIGE DERRICK LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2018
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3740 E SOUTHERN AVE STE 16&112
MESA AZ
85206-2567
US

IV. Provider business mailing address

3740 E SOUTHERN AVE STE 106&112
MESA AZ
85206-2567
US

V. Phone/Fax

Practice location:
  • Phone: 602-499-7590
  • Fax:
Mailing address:
  • Phone: 602-499-7590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number20204
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: