=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851857510
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DERRICK FORSYTHE LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2019
-----------------------------------------------------
Last Update Date | 01/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1428 N STATE HIGHWAY 47
-----------------------------------------------------
City | WARRENTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63383-1375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-676-7526
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2204 APPLEROCK DR
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63368-3855
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-676-7526
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 2018040870
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------