MEDICARE: DERRICK D LOTT LCDC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	12122	TX

General Provider Information

NPI Number	:	1851976807
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DERRICK D LOTT LCDC

Provider Business Mailing Address
First Line	:	18010 CABIN GREEN CT
Second Line	:
City	:	ATASCOCITA
State	:	TX
Zip	:	77346-3405
Country	:	US
Telephone Number	:	903-944-8702
Fax Number	:

Provider Business Practice Location Address
First Line	:	18010 CABIN GREEN CT
Second Line	:
City	:	ATASCOCITA
State	:	TX
Zip	:	77346-3405
Country	:	US
Telephone Number	:	903-944-8702
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/11/2021
Last Update Date	:	03/11/2021

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