Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YM0800X | Mental Health Counselor |
NPI | 1003231473 |
---|---|
Provider Name | Seth Thomas Derrick |
First Address | Grass Valley, CA 95945-5853 |
Second Address | Grass Valley, CA 95945-5853 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/02/2014 |
Last Update Date | 07/06/2021 |