Provider Demographics
NPI:1154778801
Name:SHANMAN, DEREK (PHD)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:
Last Name:SHANMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-2621
Mailing Address - Country:US
Mailing Address - Phone:985-492-1941
Mailing Address - Fax:
Practice Address - Street 1:311 JACKSON ST
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-2621
Practice Address - Country:US
Practice Address - Phone:985-492-1941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-23
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL-103103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst