Healthcare Provider Details

I. General information

NPI: 1619104403
Provider Name (Legal Business Name): DEREK DEVAN THOMPSON M.A. LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2009
Last Update Date: 09/12/2022
Certification Date: 09/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19750 MINKLER RD
ADAMS CENTER NY
13606-3122
US

IV. Provider business mailing address

19750 MINKLER RD
ADAMS CENTER NY
13606-3122
US

V. Phone/Fax

Practice location:
  • Phone: 956-401-8650
  • Fax:
Mailing address:
  • Phone: 956-401-8650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number007172
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301014190
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: