Healthcare Provider Details

I. General information

NPI: 1295761849
Provider Name (Legal Business Name): DERRICK DUANE AMPEY LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 03/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

626 WESTMORELAND AVE
LANSING MI
48915-1969
US

IV. Provider business mailing address

626 WESTMORELAND AVE
LANSING MI
48915-1969
US

V. Phone/Fax

Practice location:
  • Phone: 517-702-2653
  • Fax: 517-351-2733
Mailing address:
  • Phone: 517-702-2653
  • Fax: 517-351-2733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801080800
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: