=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386066512
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEREK STEWART M.ED, LPCC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2014
-----------------------------------------------------
Last Update Date | 10/20/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3439 BUCKHORN DR
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40515-1716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-271-1634
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 726
-----------------------------------------------------
City | LOUISA
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41230-0726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-271-1634
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | KY-1621
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | KY-1621
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------