Healthcare Provider Details

I. General information

NPI: 1174443493
Provider Name (Legal Business Name): DEREK SCULLIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9475 BRIAR VILLAGE PT STE 202
COLORADO SPRINGS CO
80920-7901
US

IV. Provider business mailing address

6415 TEMPLETON GAP RD APT 313
COLORADO SPRINGS CO
80923-5320
US

V. Phone/Fax

Practice location:
  • Phone: 603-312-1686
  • Fax:
Mailing address:
  • Phone: 603-312-1686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: