Healthcare Provider Details

I. General information

NPI: 1992034672
Provider Name (Legal Business Name): DERRICK SKINNER SR. LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2009
Last Update Date: 02/16/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12647 OLIVE BLVD STE 600
SAINT LOUIS MO
63141-6393
US

IV. Provider business mailing address

USA MEDDAC 11050 MOUNT BELVEDERE BLVD
FORT DRUM NY
13602-5438
US

V. Phone/Fax

Practice location:
  • Phone: 800-325-3982
  • Fax: 877-685-9880
Mailing address:
  • Phone: 315-772-3173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2406
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2406
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1041
License Number StateNE
# 4
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number1041
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: