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General NPI Number Information
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NPI Number | 1790078707
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Entity Type | Individual
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Provider Name | DEREK ANDREW GEORGE LICSW, LADC
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Gender | Male
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Dates
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Enumeration Date | 05/24/2011
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Last Update Date | 05/24/2011
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Provider Practice Location Address
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Address Line | 55 JOY DR
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City | SOUTH BURLINGTON
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State | VT
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Zip | 05403-6119
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Country | US
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Telephone | 802-658-6111
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Fax |
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Provider Business Mailing Address
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Address Line | 28 CONVENT SQ
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City | BURLINGTON
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State | VT
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Zip | 05401-5136
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Country | US
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Telephone | 802-578-7870
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 000391
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License Number State | VT
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 089.0000978
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License Number State | VT
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