Healthcare Provider Details

I. General information

NPI: 1558018309
Provider Name (Legal Business Name): DEREK SESSOM LPC-20876
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2022
Last Update Date: 03/27/2023
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4425 N 24TH ST
PHOENIX AZ
85016-5501
US

IV. Provider business mailing address

2640 N 15TH ST
PHOENIX AZ
85006-1125
US

V. Phone/Fax

Practice location:
  • Phone: 623-217-1733
  • Fax:
Mailing address:
  • Phone: 623-217-1733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-20876
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: