Healthcare Provider Details

I. General information

NPI: 1134158090
Provider Name (Legal Business Name): DERRICK LAVON HIGHTOWER LPCI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 02/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 S CHURCH ST
SPARTANBURG SC
29306-5345
US

IV. Provider business mailing address

113 BITTERNUT LN
TAYLORS SC
29687-5865
US

V. Phone/Fax

Practice location:
  • Phone: 864-230-6479
  • Fax: 864-578-7176
Mailing address:
  • Phone: 864-230-6479
  • Fax: 864-578-7176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number4714
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4714
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number4714
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: