Healthcare Provider Details

I. General information

NPI: 1518481480
Provider Name (Legal Business Name): DERRICK PRINGLE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 48TH AVE
MERIDIAN MS
39307
US

IV. Provider business mailing address

110 48TH AVE
MERIDIAN MS
39307-6719
US

V. Phone/Fax

Practice location:
  • Phone: 601-513-4359
  • Fax:
Mailing address:
  • Phone: 601-513-4359
  • Fax: 601-485-2310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC7012
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: