Healthcare Provider Details

I. General information

NPI: 1578137345
Provider Name (Legal Business Name): DERRICK ANTHONY SYKES LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2021
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 BUFORD HWY NE STE 100
BROOKHAVEN GA
30329-2146
US

IV. Provider business mailing address

9105 DARNELL PL
SAINT LOUIS MO
63136-3926
US

V. Phone/Fax

Practice location:
  • Phone: 770-389-8100
  • Fax:
Mailing address:
  • Phone: 314-580-9957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number201103628
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC007531
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: