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General NPI Number Information
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NPI Number | 1396999546
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Entity Type | Individual
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Provider Name | DERRICK HUMPHREY MS ED, LMHC
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Gender | Male
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Dates
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Enumeration Date | 11/13/2008
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Last Update Date | 08/10/2011
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Provider Practice Location Address
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Address Line | 800 S EUSTIS ST
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City | EUSTIS
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State | FL
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Zip | 32726-4886
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Country | US
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Telephone | 321-696-5598
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Fax | 407-453-4077
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Provider Business Mailing Address
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Address Line | PO BOX 2545
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City | GOLDENROD
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State | FL
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Zip | 32733-2545
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MH-10589
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License Number State | FL
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